Healthcare Provider Details

I. General information

NPI: 1962152249
Provider Name (Legal Business Name): MATTHEW IAN YODER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 VOLVO PKWY
CHESAPEAKE VA
23320-2855
US

IV. Provider business mailing address

PO BOX 1980
NORFOLK VA
23501-1980
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-4630
  • Fax: 757-668-4635
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0116037191
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: