Healthcare Provider Details

I. General information

NPI: 1699423459
Provider Name (Legal Business Name): MATTHEW RYAN MICHIENZI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALTER REED NATIONAL MILITARY MEDICAL CENTER 8901 ROCKVILLE PIKE
BETHESDA MD
20889
US

IV. Provider business mailing address

8901 ROCKVILLE PIKE
BETHESDA MD
20889
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4000
  • Fax:
Mailing address:
  • Phone: 301-295-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102208361
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: