MEDICARE: EXECUTIVE HEALTH CARE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0101036392	VA

General Provider Information

NPI Number	:	1467662197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE HEALTH CARE PC

Provider Business Mailing Address
First Line	:	4867 BAXTER RD
Second Line	:	SUITE 105
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4469
Country	:	US
Telephone Number	:	757-473-9300
Fax Number	:	757-473-9361

Provider Business Practice Location Address
First Line	:	4867 BAXTER RD
Second Line	:	SUITE 105
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4469
Country	:	US
Telephone Number	:	757-473-9300
Fax Number	:	757-473-9361

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KAMAL SELIM LOUKA II
Credential	:	MD
Telephone Number	:	757-473-9300

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	02/08/2016

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