Provider Demographics
NPI:1689668832
Name:MATON, BRUNO MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUNO
Middle Name:MICHAEL
Last Name:MATON
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 1:301 RIVERVIEW AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1065
Mailing Address - Country:US
Mailing Address - Phone:757-252-9015
Mailing Address - Fax:757-510-9041
Practice Address - Street 1:301 RIVERVIEW AVE STE 202
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1065
Practice Address - Country:US
Practice Address - Phone:757-252-9015
Practice Address - Fax:757-510-9041
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2347442084N0400X
VA01012432292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02623756Medicaid
NYRA5886Medicare ID - Type Unspecified
NYI25833Medicare UPIN