Provider Demographics
NPI:1114920253
Name:ANTHONY, ERVIN (MD)
Entity type:Individual
Prefix:
First Name:ERVIN
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 866
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23109-0866
Mailing Address - Country:US
Mailing Address - Phone:804-725-9191
Mailing Address - Fax:
Practice Address - Street 1:10980 BUCKLEY HALL ROAD
Practice Address - Street 2:BUILDING #5
Practice Address - City:MATHEWS
Practice Address - State:VA
Practice Address - Zip Code:23109-2310
Practice Address - Country:US
Practice Address - Phone:804-725-9191
Practice Address - Fax:804-725-9120
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53345207P00000X
VA0101034362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049567100Medicaid
VA1114920253Medicaid