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General NPI Number Information
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NPI Number | 1093070781
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Entity Type | Organization
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Legal Business Name | PENINSULA VASCULAR CENTER, P.C.
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Dates
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Enumeration Date | 07/09/2012
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Last Update Date | 07/09/2012
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Provider Practice Location Address
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Address Line | 501 BUTLER FARM RD SUITE B
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City | HAMPTON
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State | VA
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Zip | 23666-1777
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Country | US
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Telephone | 757-766-6080
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Fax | 757-766-6085
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Provider Business Mailing Address
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Address Line | 501 BUTLER FARM RD SUITE I
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City | HAMPTON
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State | VA
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Zip | 23666-1777
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Country | US
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Telephone | 757-766-6080
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Fax | 757-766-6085
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | KHALIL B DAHDAH
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Credential | MD
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Telephone | 757-766-6080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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