Provider Demographics
NPI:1447785688
Name:MUTCH, KEVIN JACOB (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JACOB
Last Name:MUTCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 S HENRY ST STE U2
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-3973
Mailing Address - Country:US
Mailing Address - Phone:757-206-2840
Mailing Address - Fax:
Practice Address - Street 1:2225 S HENRY ST STE U2
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3973
Practice Address - Country:US
Practice Address - Phone:757-206-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205876207Q00000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine