1265406144 NPI number — DR. EDWIN EDISON GATEWOOD M.D.

Table of content: DR. EDWIN EDISON GATEWOOD M.D. (NPI 1265406144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265406144 NPI number — DR. EDWIN EDISON GATEWOOD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GATEWOOD
Provider First Name:
EDWIN
Provider Middle Name:
EDISON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1265406144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 JOHN PAUL JONES CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23708-2111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-953-5269
Provider Business Mailing Address Fax Number:
757-953-6907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 FAIRFAX AVE
Provider Second Line Business Practice Location Address:
SUITE 710
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23507-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-446-5888
Provider Business Practice Location Address Fax Number:
757-446-5918
Provider Enumeration Date:
02/15/2006

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: 2084P0800X , with the licence number:  0101054731 , 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: 283237 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: -006 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 007110600 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAR . This is a "FIRST HEALTH COMMERCIAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0520K . This is a "BC/BS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 155139 . This is a "MHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 209852 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 263582 . This is a "UHC/MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 690520K , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89030 . This is a "SENTARA / OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VIRGINIA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 120503 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "MULTIPLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CORVEL/CORCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "USA MANAGED CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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