Healthcare Provider Details

I. General information

NPI: 1639213192
Provider Name (Legal Business Name): GEORGE KELLY HEUSER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 JACK FROST RD
VIRGINIA BEACH VA
23455-3221
US

IV. Provider business mailing address

1744 JACK FROST RD
VIRGINIA BEACH VA
23455-3221
US

V. Phone/Fax

Practice location:
  • Phone: 757-464-2330
  • Fax: 757-552-7108
Mailing address:
  • Phone: 757-464-2330
  • Fax: 757-552-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101040554
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: