Provider Demographics
NPI:1619437779
Name:BOURNE, MATTHEW DULLES (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DULLES
Last Name:BOURNE
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 1:201 E UNIVERSITY PKWY DEPT OF
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2829
Mailing Address - Country:US
Mailing Address - Phone:410-554-2284
Mailing Address - Fax:410-554-2184
Practice Address - Street 1:1100 WAYNE AVE STE 1020
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-5643
Practice Address - Country:US
Practice Address - Phone:703-390-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-23
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND215752085R0202X
MO20240397302085R0202X
MDH01008912085R0202X
GUDO-01332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology