1710025333 NPI number — DR. LUIS FAUSTINO IGNACIO MD

Table of content: DR. LUIS FAUSTINO IGNACIO MD (NPI 1710025333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710025333 NPI number — DR. LUIS FAUSTINO IGNACIO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IGNACIO
Provider First Name:
LUIS
Provider Middle Name:
FAUSTINO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1710025333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1206 FAIRWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-9400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-547-1638
Provider Business Mailing Address Fax Number:
757-549-0663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 E LITTLE CREEK RD
Provider Second Line Business Practice Location Address:
205
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23518-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-587-4744
Provider Business Practice Location Address Fax Number:
757-587-4947
Provider Enumeration Date:
02/03/2007

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:  0101046136 , 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: 71-6051-8 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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