Healthcare Provider Details

I. General information

NPI: 1689731986
Provider Name (Legal Business Name): PENINSULA PLASTIC SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 MONTICELLO AVE
WILLIAMSBURG VA
23185-2834
US

IV. Provider business mailing address

324 MONTICELLO AVE
WILLIAMSBURG VA
23185-2834
US

V. Phone/Fax

Practice location:
  • Phone: 757-229-5200
  • Fax: 757-229-2692
Mailing address:
  • Phone: 757-229-5200
  • Fax: 757-229-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101052484
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN M. PITMAN III
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 757-229-5200