Healthcare Provider Details

I. General information

NPI: 1275157745
Provider Name (Legal Business Name): JONATHON DANIEL RATKUS SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 REGULUS AVE
VIRGINIA BEACH VA
23461-2200
US

IV. Provider business mailing address

1636 REGULUS AVE
VIRGINIA BEACH VA
23461-2200
US

V. Phone/Fax

Practice location:
  • Phone: 757-862-0077
  • Fax:
Mailing address:
  • Phone: 757-862-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: