Provider Demographics
NPI:1235225624
Name:FEDOR, MATTHEW C (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:FEDOR
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:PO BOX 886
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-0886
Mailing Address - Country:US
Mailing Address - Phone:503-814-4440
Mailing Address - Fax:503-814-4444
Practice Address - Street 1:610 HAWTHORNE AVE SE STE 110
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-814-4440
Practice Address - Fax:503-814-4444
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27542207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274652Medicaid
ORR152647OtherMEDICARE
OR274652Medicaid
NE47070592313Medicaid