1487072799 NPI number — KEAN O FEYZEAU MD

Table of content: KEAN O FEYZEAU MD (NPI 1487072799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487072799 NPI number — KEAN O FEYZEAU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEYZEAU
Provider First Name:
KEAN
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487072799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 FAIRFAX AVE., 6TH FLOOR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23507-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-446-8937
Provider Business Mailing Address Fax Number:
757-446-8951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 GRESHAM DR
Provider Second Line Business Practice Location Address:
RALEIGH BUILDINE, SUITE #304
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-388-3397
Provider Business Practice Location Address Fax Number:
757-388-2885
Provider Enumeration Date:
04/03/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 0101264443 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0101264443 . This is a "VIRGINIA STATE MEDICAL LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".