Provider Demographics
NPI:1083674212
Name:ANDERSON, MATTHEW S (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:S
Last Name:ANDERSON
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 1:1265 W AMERICAN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1405
Mailing Address - Country:US
Mailing Address - Phone:920-722-7747
Mailing Address - Fax:
Practice Address - Street 1:600 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904
Practice Address - Country:US
Practice Address - Phone:920-722-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42988-020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083674212Medicaid
WIW12074008Medicare PIN
WI1083674212Medicaid
WIH33528Medicare UPIN
WIW12073008Medicare PIN