Provider Demographics
NPI:1538279260
Name:HAMPTON ROADS PODIATRY PC
Entity type:Organization
Organization Name:HAMPTON ROADS PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-497-0859
Mailing Address - Street 1:5241 PRINCESS ANNE ROAD SUITE 102
Mailing Address - Street 2:
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-497-0859
Mailing Address - Fax:757-497-0976
Practice Address - Street 1:5241 PRINCESS ANNE ROAD SUITE 102
Practice Address - Street 2:
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-497-0859
Practice Address - Fax:757-497-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103001041213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9304240Medicaid
VA9304240Medicaid