Provider Demographics
NPI:1235149139
Name:THEADO, MATTHEW R (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:THEADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 REDBIRD CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7977
Mailing Address - Country:US
Mailing Address - Phone:920-338-6820
Mailing Address - Fax:920-338-6829
Practice Address - Street 1:555 REDBIRD CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7977
Practice Address - Country:US
Practice Address - Phone:920-338-6820
Practice Address - Fax:920-338-6829
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI39636208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32447000Medicaid
WI32447000Medicaid
G74053Medicare UPIN
WI073550090Medicare Oscar/Certification