Integrated Dermatology of Tidewater LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

INTEGRATED DERMATOLOGY OF TIDEWATER LLC

Practice address

885 Kempsville Rd Ste 309
Norfolk, VA 23502-3800

Phone

(757) 461-1033

NPI assigned

Jul 24, 2013

Last updated

Jan 29, 2019By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mr. Jeffrey D Queen

Title

Owner

Phone

(514) 314-2000

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in VA

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 25

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.

• Bruce Evans Fuller, M.D.

  • Dermatology Physician
  • Norfolk, VA
  • NPI 1538117890
  Medicare reassignment Care Compare group NPD
• Elizabeth Gibson, NP

  • Family Nurse Practitioner
  • Norfolk, VA
  • NPI 1649012303
  Medicare reassignment Care Compare group NPD
• Anis Miladi, M.D.

  • MOHS-Micrographic Surgery Physician
  • Portsmouth, VA
  • NPI 1003879495
  Medicare reassignment Care Compare group NPD
• John W Roman, M.D.

  • Dermatology Physician
  • Norfolk, VA
  • NPI 1700148277
  Medicare reassignment Care Compare group NPD
• Jonathan L Schreiber, MD

  • Dermatology Physician
  • Norfolk, VA
  • NPI 1689785578
  Medicare reassignment Care Compare group NPD
• Kelly Gail Barriault, PA

  • Medical Physician Assistant
  • Norfolk, VA
  • NPI 1164492138
  Medicare reassignment Care Compare group
• Kevin Kurt Charles, PA-C

  • Physician Assistant
  • Fort Eustis, VA
  • NPI 1275739435
  Medicare reassignment Care Compare group
• Julie Bailey Johnson, PA-C

  • Physician Assistant
  • Norfolk, VA
  • NPI 1568512465
  Medicare reassignment Care Compare group
• Indira Sookdeo, PA-C

  • Physician Assistant
  • Norfolk, VA
  • NPI 1669146486
  Medicare reassignment Care Compare group
• Kristin Dorotich

  • Nurse Practitioner
  • Richmond, VA
  • NPI 1376972679
  NPD
• Kimberly Ann Hagopian

  • Family Nurse Practitioner
  • Fairfax, VA
  • NPI 1396579090
  NPD
• Larry L Legum, M.D.

  • Specialist
  • Chesapeake, VA
  • NPI 1639101256
  NPD

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

{
    "created_epoch": "1374624000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1548720000000",
    "number": "1801238472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 EXCHANGE CT STE 110",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334314450",
            "telephone_number": "561-314-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "885 KEMPSVILLE RD STE 309",
            "city": "NORFOLK",
            "state": "VA",
            "postal_code": "235023800",
            "telephone_number": "757-461-1033"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRATED DERMATOLOGY OF TIDEWATER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-07-24",
        "last_updated": "2019-01-29",
        "status": "A",
        "authorized_official_last_name": "QUEEN",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "514-314-2000",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dermatology Physician in Norfolk, VA
• Providers in Norfolk, VA by specialty
• Dermatology Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 29, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.