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General NPI Number Information
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NPI Number | 1881702058
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Entity Type | Organization
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Legal Business Name | FIRST COLONIAL UROLOGICAL ASS
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 02/20/2008
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Provider Practice Location Address
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Address Line | 4501 B WITCHDUCK RD
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City | VA BEACH
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State | VA
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Zip | 23455
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Country | US
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Telephone | 757-499-4932
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Fax | 757-490-6693
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Provider Business Mailing Address
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Address Line | 4501 N WITCHDUCK RD
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City | VA BEACH
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State | VA
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Zip | 23455
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Country | US
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Telephone | 757-499-4932
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Fax | 757-490-6693
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Authorized Official
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Title or Position | PRESIDENT OF CORP
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Name | CHARLES STANLEY DAVIS JR.
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Credential | MD
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Telephone | 757-499-4932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 0101018138
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License Number State | VA
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