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General NPI Number Information
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NPI Number | 1467579482
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Entity Type | Organization
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Legal Business Name | TIDEWATER MEDICAL CLINIC PC
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 111 COASTAL WAY
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City | CHESAPEAKE
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State | VA
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Zip | 23320-4603
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Country | US
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Telephone | 757-549-9671
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Fax | 757-549-6802
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Provider Business Mailing Address
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Address Line | 111 COASTAL WAY
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City | CHESAPEAKE
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State | VA
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Zip | 23320-4603
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Country | US
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Telephone | 757-549-9671
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Fax | 757-549-6802
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LUIS G. CARPIO
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Credential | M.D.
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Telephone | 757-549-9671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 0101055402
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License Number State | VA
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