Healthcare Provider Details

I. General information

NPI: 1881702058
Provider Name (Legal Business Name): FIRST COLONIAL UROLOGICAL ASS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 B WITCHDUCK RD
VA BEACH VA
23455
US

IV. Provider business mailing address

4501 N WITCHDUCK RD
VA BEACH VA
23455
US

V. Phone/Fax

Practice location:
  • Phone: 757-499-4932
  • Fax: 757-490-6693
Mailing address:
  • Phone: 757-499-4932
  • Fax: 757-490-6693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101018138
License Number StateVA

VIII. Authorized Official

Name: CHARLES STANLEY DAVIS JR.
Title or Position: PRESIDENT OF CORP
Credential: MD
Phone: 757-499-4932