Healthcare Provider Details

I. General information

NPI: 1932461936
Provider Name (Legal Business Name): ANTHONY JOSEPH CAVALLO D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5253 PROVIDENCE RD STE 100
VIRGINIA BEACH VA
23464-4201
US

IV. Provider business mailing address

5253 PROVIDENCE RD STE 100
VIRGINIA BEACH VA
23464-4201
US

V. Phone/Fax

Practice location:
  • Phone: 757-252-4640
  • Fax: 757-510-9343
Mailing address:
  • Phone: 757-252-4640
  • Fax: 757-510-9343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0116024925
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301189
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: