Healthcare Provider Details

I. General information

NPI: 1750462628
Provider Name (Legal Business Name): TIDEWATER FAMILY PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 HAYGOOD RD
VIRGINIA BEACH VA
23455-5436
US

IV. Provider business mailing address

4660 HAYGOOD RD
VIRGINIA BEACH VA
23455-5436
US

V. Phone/Fax

Practice location:
  • Phone: 757-460-0243
  • Fax: 757-460-1011
Mailing address:
  • Phone: 757-460-0243
  • Fax: 757-460-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID BRANNON HOLT
Title or Position: OWNER
Credential: M.D.
Phone: 757-460-0243