Provider Demographics
NPI:1083624084
Name:MITSCH, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MITSCH
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:SUITE 6
Mailing Address - Street 2:1821 OLD DONATION PARKWAY
Mailing Address - City:VIRGINIA BCH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3033
Mailing Address - Country:US
Mailing Address - Phone:757-496-4864
Mailing Address - Fax:757-496-4942
Practice Address - Street 1:SUITE 6
Practice Address - Street 2:1821 OLD DONATION PARKWAY
Practice Address - City:VIRGINIA BCH
Practice Address - State:VA
Practice Address - Zip Code:23454-3033
Practice Address - Country:US
Practice Address - Phone:757-496-4864
Practice Address - Fax:757-496-4942
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052465174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA333299OtherMAMSI
VA54-1816313OtherVA. HEALTH NETWORK
VA44740849OtherMULTI-PLAN PPO
VA54-1816313OtherAARP
VA0499149OtherGHI
VA142942XXOtherPREFERRED CARE
VA54-1816313OtherTRICARE
VA54-1816313OtherMAILHANDLERS
VA600212807OtherCIGNA
VA54-1816313OtherAETNA
VA54-1816313OtherUNITED HEALTHCARE
VA6900925Medicaid
VA380172OtherANTHEM
VA54-1816313OtherPRIORITY HEALTHCARE INC.
VA3078121OtherCIGNA PPO
VA61240OtherOPTIMA
VA843259OtherFIRST HEALTH
VAG12085Medicare UPIN
VA54-1816313OtherTRICARE