Provider Demographics
NPI:1023017522
Name:ENZWEILER, MATTHEW (DPM)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:ENZWEILER
Suffix:
Gender:M
Credentials:DPM
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-212-0175
Mailing Address - Fax:859-746-7464
Practice Address - Street 1:525 ALEXANDRIA PIKE
Practice Address - Street 2:SUITE 230
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071
Practice Address - Country:US
Practice Address - Phone:859-441-4334
Practice Address - Fax:859-441-3698
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00223213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90290081Medicaid
KY80002231Medicaid
KYK122170Medicare PIN
KY0646402Medicare PIN
KY6464Medicare PIN
KYU65932Medicare UPIN
KY2013804Medicare PIN
KY0390102Medicare PIN
KY2011204Medicare PIN
KY3901Medicare PIN
KY80002231Medicaid
KY8569Medicare PIN