Healthcare Provider Details

I. General information

NPI: 1477502250
Provider Name (Legal Business Name): JESSE W ST CLAIR III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 OLD DONATION PARKWAY
VIRGINIA BEACH VA
23454-3064
US

IV. Provider business mailing address

PO BOX 7068
PORTSMOUTH VA
23707-0068
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-5300
  • Fax: 757-213-9341
Mailing address:
  • Phone: 757-686-3516
  • Fax: 757-686-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101032201
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: