Healthcare Provider Details

I. General information

NPI: 1275132235
Provider Name (Legal Business Name): TIDEWATER LUNG AND SLEEP CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 BREEZEPORT WAY STE 600
SUFFOLK VA
23435-3731
US

IV. Provider business mailing address

1500 BREEZEPORT WAY STE 600
SUFFOLK VA
23435-3731
US

V. Phone/Fax

Practice location:
  • Phone: 757-528-8245
  • Fax: 757-394-1132
Mailing address:
  • Phone: 757-528-8245
  • Fax: 757-394-1132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAJNISH DHAWAN
Title or Position: PROVIDER
Credential: MD
Phone: 757-771-7099