Provider Demographics
NPI:1629889308
Name:TIDEWATER ALLERGY AND ASTHMA LLC
Entity type:Organization
Organization Name:TIDEWATER ALLERGY AND ASTHMA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-572-6052
Mailing Address - Street 1:1828 DUKE OF NORFOLK QUAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4534 BONNEY RD STE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3873
Practice Address - Country:US
Practice Address - Phone:757-499-4101
Practice Address - Fax:757-497-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-14
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty