Basic Information
Provider Information | |||||||||
NPI: | 1962407510 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PASCHOLD | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 SENTARA CIRCLE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | WILLIAMSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 231885727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572292236 | ||||||||
FaxNumber: | 7572210409 | ||||||||
Practice Location | |||||||||
Address1: | 500 SENTARA CIRCLE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | WILLIAMSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 231885727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572292236 | ||||||||
FaxNumber: | 7572210409 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2005 | ||||||||
LastUpdateDate: | 11/29/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101059022 | VA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | P00016047 | 01 | VA | RAILROAD MEDICARE | OTHER | 65593 | 01 | VA | OPTIMA | OTHER |