Provider Demographics
NPI:1710945415
Name:MAYR, MATTHEW THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:MAYR
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 1:1651 N PARHAM RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4605
Mailing Address - Country:US
Mailing Address - Phone:804-288-8248
Mailing Address - Fax:804-282-6223
Practice Address - Street 1:1651 N PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4605
Practice Address - Country:US
Practice Address - Phone:804-288-8248
Practice Address - Fax:804-282-6223
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101236365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010095018Medicaid
VA2128643OtherMDIPA,MAMSI,OPTIMUM CHOIC
VA54-1739189OtherFED TAX ID
VA7891521OtherAETNA
VA52224OtherCARENET-MEDICAID
VA2410421OtherUNITED HEALTHCARE
VA3611772OtherUS HEALTHCARE-AETNA HMO
VA371483100OtherUS DEPT OF LABOR
VA245575OtherSOUTHERN HEALTH
VA3600542OtherCIGNA
VA143843OtherANTHEM BC/BS
VA90412OtherSENTARA-OPTIMA HEALTH
VA7891521OtherAETNA
VA143843OtherANTHEM BC/BS