Basic Information
| Provider Information | |||||||||
| NPI: | 1376510941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAITEKUS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 TUSCANY DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573019200 | ||||||||
| FaxNumber: | 7573019246 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 TUSCANY DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573019200 | ||||||||
| FaxNumber: | 7573019246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101102632 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.