Healthcare Provider Details

I. General information

NPI: 1629889308
Provider Name (Legal Business Name): TIDEWATER ALLERGY AND ASTHMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4534 BONNEY RD STE B
VIRGINIA BEACH VA
23462-3873
US

IV. Provider business mailing address

1828 DUKE OF NORFOLK QUAY
VIRGINIA BEACH VA
23454-1106
US

V. Phone/Fax

Practice location:
  • Phone: 757-499-4101
  • Fax: 757-497-2419
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMY RAY OWENS
Title or Position: OWNER
Credential: MD
Phone: 757-572-6052