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General NPI Number Information
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NPI Number | 1629889308
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Entity Type | Organization
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Legal Business Name | TIDEWATER ALLERGY AND ASTHMA LLC
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Dates
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Enumeration Date | 01/14/2025
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Last Update Date | 04/03/2025
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Provider Practice Location Address
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Address Line | 4534 BONNEY RD STE B
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-3873
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Country | US
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Telephone | 757-499-4101
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Fax | 757-497-2419
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Provider Business Mailing Address
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Address Line | 1828 DUKE OF NORFOLK QUAY
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-1106
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEREMY RAY OWENS
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Credential | MD
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Telephone | 757-572-6052
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number |
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License Number State |
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