Provider Demographics
NPI:1215361449
Name:SANDRIDGE, MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SANDRIDGE
Suffix:
Gender:M
Credentials:DO
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 980257
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0257
Mailing Address - Country:US
Mailing Address - Phone:804-828-9783
Mailing Address - Fax:
Practice Address - Street 1:1213 E CLAY ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5071
Practice Address - Country:US
Practice Address - Phone:804-828-0996
Practice Address - Fax:804-828-0648
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022038902083A0100X
VA1215361449207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN