Provider Demographics
NPI:1164486064
Name:WELTER, MATTHEW JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:WELTER
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 1:1915 E 13000 N
Mailing Address - Street 2:
Mailing Address - City:COVE
Mailing Address - State:UT
Mailing Address - Zip Code:84320-2130
Mailing Address - Country:US
Mailing Address - Phone:435-713-1300
Mailing Address - Fax:435-787-7601
Practice Address - Street 1:1219 N 400 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2321
Practice Address - Country:US
Practice Address - Phone:435-757-8943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5934541-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH75709Medicare UPIN
UT005813101Medicare ID - Type Unspecified