Provider Demographics
NPI:1154372712
Name:BUTKOVICH, BRADLEY T (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:BUTKOVICH
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 1:230 CLEARFIELD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:6160 KEMPSVILLE CIR
Practice Address - Street 2:SUITE 200B
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3933
Practice Address - Country:US
Practice Address - Phone:757-321-3383
Practice Address - Fax:757-321-3332
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237415207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05501OtherMEDICARE GROUP PIN
VA1154372712Medicaid
VAI31942Medicare UPIN
VAC05501OtherMEDICARE GROUP PIN