Provider Demographics
NPI:1356879092
Name:MATVEEV, ANTON
Entity type:Individual
Prefix:
First Name:ANTON
Middle Name:
Last Name:MATVEEV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 KING ST STE 110
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1737 KING ST STE 110
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2727
Practice Address - Country:US
Practice Address - Phone:240-754-7954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD94668208100000X
VA0101275750208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation