Healthcare Provider Details

I. General information

NPI: 1811211394
Provider Name (Legal Business Name): DIGESTIVE DISEASE CENTER OF VIRGINIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 IRONBOUND RD SUITE 201
WILLIAMSBURG VA
23188-2666
US

IV. Provider business mailing address

5424 DISCOVERY PARK BLVD SUITE 203
WILLIAMSBURG VA
23188-2862
US

V. Phone/Fax

Practice location:
  • Phone: 757-232-8769
  • Fax: 757-232-8875
Mailing address:
  • Phone: 757-232-8769
  • Fax: 757-232-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101049148
License Number StateVA

VIII. Authorized Official

Name: RICHARD J HARTLE
Title or Position: PHYSICIAN
Credential: MD
Phone: 757-232-8769