Provider Demographics
NPI:1124401054
Name:LOOSE, MATTHEW G (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:G
Last Name:LOOSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1251 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17003-1643
Mailing Address - Country:US
Mailing Address - Phone:717-867-4671
Mailing Address - Fax:717-867-4981
Practice Address - Street 1:1251 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:PA
Practice Address - Zip Code:17003-1643
Practice Address - Country:US
Practice Address - Phone:717-867-4671
Practice Address - Fax:717-867-4981
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS018483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103328630Medicaid