Provider Demographics
NPI:1306883202
Name:VISCONTI, MATTHEW L (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:VISCONTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1114 CHARLEVOIX AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9701
Mailing Address - Country:US
Mailing Address - Phone:231-439-9700
Mailing Address - Fax:231-439-9709
Practice Address - Street 1:1114 CHARLEVOIX AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9701
Practice Address - Country:US
Practice Address - Phone:231-439-9700
Practice Address - Fax:231-439-9709
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43014073902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4926793Medicaid
MI4777030Medicaid
MI4732181Medicaid
MI4356252Medicaid
P25410001Medicare PIN
MI4732181Medicaid
MI4777030Medicaid
P34680001Medicare PIN