Provider Demographics
NPI:1295782407
Name:MAULBETSCH, BRUCE (DO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MAULBETSCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:804-217-7991
Practice Address - Street 1:12997 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-369-9446
Practice Address - Fax:757-369-9554
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDH0054131207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1295782407Medicaid
VA1295782407Medicaid
MDB46923Medicare UPIN