Healthcare Provider Details

I. General information

NPI: 1902862071
Provider Name (Legal Business Name): GASTROENTEROLOGY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 WILL O'WISP DRIVE SUITE 200
VIRGINIA BEACH VA
23454-2409
US

IV. Provider business mailing address

1717 WILL O'WISP DRIVE SUITE 200
VIRGINIA BEACH VA
23454-2409
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-4817
  • Fax: 757-481-7138
Mailing address:
  • Phone: 757-481-4817
  • Fax: 757-481-7138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number201628793
License Number StateVA

VIII. Authorized Official

Name: JAN A JANSON
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 757-481-5730