Healthcare Provider Details

I. General information

NPI: 1154372712
Provider Name (Legal Business Name): BRADLEY T BUTKOVICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 KEMPSVILLE CIR SUITE 200B
NORFOLK VA
23502-3933
US

IV. Provider business mailing address

230 CLEARFIELD AVE SUITE 124
VIRGINIA BEACH VA
23462-1832
US

V. Phone/Fax

Practice location:
  • Phone: 757-321-3383
  • Fax: 757-321-3332
Mailing address:
  • Phone: 757-321-3383
  • Fax: 757-321-3332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101237415
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0101237415
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: