NPIMap

Organization Active NPI

Tidewater Medical Care PC

  • Family Medicine Physician
  • Virginia Beach, VA
National Provider Identifier
1053558981
Registry record updated Feb 3, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
0101058505 Issued in VA
Legal business name
TIDEWATER MEDICAL CARE PC
Doing business as
Tidewater Medical Care PC
Practice address
4608 Thoroughgood Drive
Virginia Beach, VA 23455
Phone
(757) 965-9465
Fax
(757) 965-9491
NPI assigned
Jan 14, 2009
Last updated
Feb 3, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 3, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Migdonia Montejo, M.D.NPI 1467459347
Title
Owner/President
Phone
(757) 965-9465

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 0101058505 VA Primary

Addresses

Primary practice location

4608 Thoroughgood Drive
Virginia Beach, VA 23455

Mailing address

4608 Thoroughgood Drive
Virginia Beach, VA 23455
Phone (757) 965-9465

Other names 1

  • Tidewater Medical Care PC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090715000076 VA Part B Supplier - Clinic/Group Practice 9133271661 Receives reassigned benefits from 9 practitioners
Practice locations: Virginia Beach, VA

National Provider Directory

National Provider Directory

Locations

109 Wimbledon Sq
Ste G1
Chesapeake, VA 23320
Phone (757) 965-9465

2101 Parks Ave
Ste 305
Virginia Beach, VA 23451
Phone (757) 749-2308

3330 Pacific Ave
Ste 200
Virginia Beach, VA 23451
Phone (757) 965-9465

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1231891200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1265155200000",
    "number": "1053558981",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4608 THOROUGHGOOD DRIVE",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "23455",
            "telephone_number": "757-965-9465",
            "fax_number": "757-965-9491"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4608 THOROUGHGOOD DRIVE",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "23455",
            "telephone_number": "757-965-9465",
            "fax_number": "757-965-9491"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER MEDICAL CARE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-14",
        "last_updated": "2010-02-03",
        "status": "A",
        "authorized_official_last_name": "MONTEJO",
        "authorized_official_first_name": "MIGDONIA",
        "authorized_official_title_or_position": "OWNER/PRESIDENT",
        "authorized_official_telephone_number": "757-965-9465",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "VA",
            "license": "0101058505",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tidewater Medical Care PC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Virginia Beach, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 3, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.