Provider Demographics
NPI:1730278243
Name:STEWART WETCHLER & MARY KAY DINEEN
Entity type:Organization
Organization Name:STEWART WETCHLER & MARY KAY DINEEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WETCHLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-874-8696
Mailing Address - Street 1:12700 MCMANUS BLVD
Mailing Address - Street 2:SUITE 102A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4407
Mailing Address - Country:US
Mailing Address - Phone:757-874-8696
Mailing Address - Fax:757-872-9904
Practice Address - Street 1:12700 MCMANUS BLVD
Practice Address - Street 2:SUITE 102A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4407
Practice Address - Country:US
Practice Address - Phone:757-874-8696
Practice Address - Fax:757-872-9904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID #