Provider Demographics
NPI:1407165004
Name:MATHEW, VINOD
Entity Type:Individual
Prefix:MR
First Name:VINOD
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19490 SANDRIDGE WAY
Mailing Address - Street 2:STE 170
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3467
Mailing Address - Country:US
Mailing Address - Phone:703-415-6037
Mailing Address - Fax:703-723-4564
Practice Address - Street 1:19465 DEERFIELD AVE STE 108
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-1702
Practice Address - Country:US
Practice Address - Phone:703-415-6037
Practice Address - Fax:703-986-3205
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205535225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist