Healthcare Provider Details

I. General information

NPI: 1477715811
Provider Name (Legal Business Name): CHRISTOPHER S MUDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 LEE ST
CHARLOTTESVILLE VA
22908-0817
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-9333
  • Fax: 434-243-0064
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD13443
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberMD13443
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101259647
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: