Provider Demographics
NPI:1508838244
Name:MATHESON, VIRGINIA GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:GRACE
Last Name:MATHESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46050 MANEKIN PLZ STE 110
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-6519
Mailing Address - Country:US
Mailing Address - Phone:703-218-8500
Mailing Address - Fax:703-359-0463
Practice Address - Street 1:46050 MANEKIN PLZ STE 110
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-6519
Practice Address - Country:US
Practice Address - Phone:703-218-8500
Practice Address - Fax:703-359-0463
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350815182084P0800X, 2084P0804X
VA01012797172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3120723Medicaid