Healthcare Provider Details

I. General information

NPI: 1104086743
Provider Name (Legal Business Name): MATTHEW W. ISENHOWER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

134 BUSINESS PARK DR
VIRGINIA BEACH VA
23462-6523
US

V. Phone/Fax

Practice location:
  • Phone: 757-473-0055
  • Fax: 757-473-0075
Mailing address:
  • Phone: 757-473-0055
  • Fax: 757-473-0075

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 TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME112193
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101246603
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: