Provider Demographics
NPI:1518903491
Name:MATHERN, BRUCE E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:MATHERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:417 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5002
Practice Address - Country:US
Practice Address - Phone:804-828-9165
Practice Address - Fax:804-828-0374
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052126207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6103456 - 541581185Medicaid
VA490032CG09729OtherCMS SECTION 1011 MCV PHYS
VA490032CG09729OtherCMS SECTION 1011 MCV PHYS
VA140000149 - C03698Medicare ID - Type UnspecifiedMCV PHYSICIANS