Healthcare Provider Details

I. General information

NPI: 1255325254
Provider Name (Legal Business Name): KERRY C PREWITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/09/2025
Certification Date: 08/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 BULIFANTS BLVD STE A
WILLIAMSBURG VA
23188-5719
US

IV. Provider business mailing address

445 CHARLES H DIMMOCK PKWY STE 100
COLONIAL HEIGHTS VA
23834-2990
US

V. Phone/Fax

Practice location:
  • Phone: 804-520-1764
  • Fax:
Mailing address:
  • Phone: 804-520-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0057329
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberD0057329
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number0101041337
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101041337
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: