Healthcare Provider Details

I. General information

NPI: 1982285615
Provider Name (Legal Business Name): MATTHEW WADE MCMULLEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 OLD IVY WAY STE 104
CHARLOTTESVILLE VA
22903-4896
US

IV. Provider business mailing address

310 OLD IVY WAY STE 104
CHARLOTTESVILLE VA
22903-4896
US

V. Phone/Fax

Practice location:
  • Phone: 434-358-9090
  • Fax: 434-243-6970
Mailing address:
  • Phone: 434-358-9090
  • Fax: 434-243-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number032.0134301
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number032.0134301
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: