Provider Demographics
NPI:1215963129
Name:MATHEWS, JOHN JOSEPH JR
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:MATHEWS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10340 DEMOCRACY LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2518
Mailing Address - Country:US
Mailing Address - Phone:703-218-2970
Mailing Address - Fax:703-218-2965
Practice Address - Street 1:10340 DEMOCRACY LN
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2518
Practice Address - Country:US
Practice Address - Phone:703-218-2970
Practice Address - Fax:703-218-2965
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038513207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5803241Medicaid
110171875OtherMEDICARE RR
VA5803241Medicaid
457449F97Medicare ID - Type Unspecified