Provider Demographics
NPI:1215269097
Name:TIDEWATER SKIN CARE AND PATHOLOGY PC
Entity type:Organization
Organization Name:TIDEWATER SKIN CARE AND PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PADMAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MENON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-825-1846
Mailing Address - Street 1:1157 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2432
Mailing Address - Country:US
Mailing Address - Phone:757-333-8001
Mailing Address - Fax:757-333-8002
Practice Address - Street 1:1157 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2432
Practice Address - Country:US
Practice Address - Phone:757-333-8001
Practice Address - Fax:757-333-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101022994207N00000X
NC200301017207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty