Healthcare Provider Details

I. General information

NPI: 1548576747
Provider Name (Legal Business Name): TIMOTHY JAMES BUNTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 06/25/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 HUGUENOT RD STE 117
MIDLOTHIAN VA
23113-5604
US

IV. Provider business mailing address

1807 HUGUENOT RD STE 117
MIDLOTHIAN VA
23113-5604
US

V. Phone/Fax

Practice location:
  • Phone: 804-506-0526
  • Fax: 804-506-0526
Mailing address:
  • Phone: 617-655-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number253660
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: