Provider Demographics
NPI:1609806363
Name:GWATHMEY, WILLIAM BROOKE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BROOKE
Last Name:GWATHMEY
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 130
Mailing Address - Street 2:
Mailing Address - City:SAINT STEPHENS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:23148-0130
Mailing Address - Country:US
Mailing Address - Phone:804-769-0103
Mailing Address - Fax:804-769-0508
Practice Address - Street 1:142 SMITHFIELD ROAD
Practice Address - Street 2:
Practice Address - City:SAINT STEPHENS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:23148-0041
Practice Address - Country:US
Practice Address - Phone:804-769-0103
Practice Address - Fax:804-769-0508
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA396132OtherANTHEM
VA96463OtherSOUTHERN HEALTH
4136177OtherAETNA
9539377OtherCIGNA
21743OtherOPTIMA HEALTH PLAN
VAB08035Medicare UPIN