MEDICARE: MATTHEW DULLES BOURNE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	DO-06857	IA
2	2085R0202X	Diagnostic Radiology Physician	H0100891	MD
3	2085R0202X	Diagnostic Radiology Physician	21575	ND
4	2085R0202X	Diagnostic Radiology Physician	2024039730	MO
5	2085R0202X	Diagnostic Radiology Physician	DO-0133	GU

General Provider Information

NPI Number	:	1619437779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW DULLES BOURNE DO

Provider Business Mailing Address
First Line	:	201 E UNIVERSITY PKWY DEPT OF
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-2829
Country	:	US
Telephone Number	:	410-554-2284
Fax Number	:	410-554-2184

Provider Business Practice Location Address
First Line	:	1100 WAYNE AVE STE 1020
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-5643
Country	:	US
Telephone Number	:	703-390-9882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2019
Last Update Date	:	09/23/2025

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