Basic Information
Provider Information | |||||||||
NPI: | 1346483567 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZYDRON | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | TERRY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., M.B.A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TERRY | ||||||||
OtherFirstName: | COURTNEY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D.,M.B.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 736 BATTLEFIELD BLVD N | ||||||||
Address2: |   | ||||||||
City: | CHESAPEAKE | ||||||||
State: | VA | ||||||||
PostalCode: | 233204941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574909388 | ||||||||
FaxNumber: | 7574909401 | ||||||||
Practice Location | |||||||||
Address1: | 4536 BONNEY RD | ||||||||
Address2: | SUITE A | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 234623818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574909388 | ||||||||
FaxNumber: | 7574909401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2009 | ||||||||
LastUpdateDate: | 05/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 0101250543 | VA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.