Provider Demographics
NPI:1083097836
Name:FUGLESTAD, MATTHEW ANDERS (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANDERS
Last Name:FUGLESTAD
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 1:5443 HAMILTON STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132
Mailing Address - Country:US
Mailing Address - Phone:320-905-1990
Mailing Address - Fax:
Practice Address - Street 1:983280 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-3280
Practice Address - Country:US
Practice Address - Phone:402-559-5510
Practice Address - Fax:402-559-6749
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE30144208600000X
FL154504208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery