Provider Demographics
NPI:1306904800
Name:DIABETIC FOOT CENTER OF TIDEWATER
Entity type:Organization
Organization Name:DIABETIC FOOT CENTER OF TIDEWATER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-461-4500
Mailing Address - Street 1:5900 E. VIRGINIA BEACH BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502
Mailing Address - Country:US
Mailing Address - Phone:757-461-4500
Mailing Address - Fax:757-466-0928
Practice Address - Street 1:5900 E. VIRGINIA BEACH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502
Practice Address - Country:US
Practice Address - Phone:757-461-4500
Practice Address - Fax:757-466-0928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty