Healthcare Provider Details

I. General information

NPI: 1912566316
Provider Name (Legal Business Name): MATTHEW ROBERT DERNBACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-8025
  • Fax: 540-853-5011
Mailing address:
  • Phone: 540-224-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLL82593
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101288165
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: