Basic Information
Provider Information | |||||||||
NPI: | 1265406144 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GATEWOOD | ||||||||
FirstName: | EDWIN | ||||||||
MiddleName: | EDISON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 620 JOHN PAUL JONES CIR | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | VA | ||||||||
PostalCode: | 237082111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7579535269 | ||||||||
FaxNumber: | 7579536907 | ||||||||
Practice Location | |||||||||
Address1: | 825 FAIRFAX AVE | ||||||||
Address2: | SUITE 710 | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235071914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574465888 | ||||||||
FaxNumber: | 7574465918 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2006 | ||||||||
LastUpdateDate: | 10/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 0101054731 | VA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 283237 | 01 | VA | ANTHEM | OTHER | -006 | 01 | VA | TRICARE/CHAMPUS | OTHER | 007110600 | 05 | VA |   | MEDICAID | PAR | 01 | VA | FIRST HEALTH COMMERCIAL | OTHER | 0520K | 01 | NC | BC/BS | OTHER | 155139 | 01 |   | MHN | OTHER | 209852 | 01 |   | MAGELLAN | OTHER | 263582 | 01 | VA | UHC/MAMSI | OTHER | 690520K | 05 | NC |   | MEDICAID | 89030 | 01 | VA | SENTARA / OPTIMA | OTHER | PAR | 01 | VA | AETNA | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | 120503 | 01 |   | VALUE OPTIONS | OTHER | PAR | 01 | VA | CIGNA BEHAVIORAL HEALTH | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER |