Provider Demographics
NPI:1114021490
Name:PASTORE, MATHIAS MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:MATHIAS
Middle Name:MICHAEL
Last Name:PASTORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12300 BERMUDA CROSSROADS LANE
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831
Mailing Address - Country:US
Mailing Address - Phone:804-748-2763
Mailing Address - Fax:804-796-2621
Practice Address - Street 1:12300 BERMUDA CROSSROADS LANE
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831
Practice Address - Country:US
Practice Address - Phone:804-748-2763
Practice Address - Fax:804-796-2621
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA0104001122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
172877OtherANTHEM BCBS
VAOOW562BO2Medicare ID - Type Unspecified
172877OtherANTHEM BCBS