Provider Demographics
NPI:1295950269
Name:PINCKENS, CEDRIC D (MD)
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:D
Last Name:PINCKENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GRESHAM DR
Mailing Address - Street 2:SUITE 503
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1901
Mailing Address - Country:US
Mailing Address - Phone:757-623-7575
Mailing Address - Fax:
Practice Address - Street 1:400 GRESHAM DR
Practice Address - Street 2:SUITE 503
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1901
Practice Address - Country:US
Practice Address - Phone:757-623-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007303874Medicaid
VA45066OtherOPTIMA
VA054985OtherBC/BS
VA007303874Medicaid
VAF39873Medicare UPIN