Provider Demographics
NPI:1568699841
Name:MUDRICK, COLIN ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:ALEXANDER
Last Name:MUDRICK
Suffix:
Gender:M
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:PO BOX 71690
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1690
Mailing Address - Country:US
Mailing Address - Phone:804-288-2830
Mailing Address - Fax:804-288-2850
Practice Address - Street 1:1501 MAPLE AVE
Practice Address - Street 2:SUITE 200, NW MOB
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2553
Practice Address - Country:US
Practice Address - Phone:804-285-2300
Practice Address - Fax:804-285-8420
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00777207X00000X
VA0101258423207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1568699841Medicaid
VA1568699841Medicaid
SCNC2092Medicaid
NC0397730024Medicare NSC