Healthcare Provider Details

I. General information

NPI: 1730940271
Provider Name (Legal Business Name): DEMETRIS DEWAYNE ALDRIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 UNIVERSITY DR
VIRGINIA BEACH VA
23453-8083
US

IV. Provider business mailing address

1881 UNIVERSITY DR
VIRGINIA BEACH VA
23453-8083
US

V. Phone/Fax

Practice location:
  • Phone: 757-775-6694
  • Fax:
Mailing address:
  • Phone: 757-775-6694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number9533725
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: