Provider Demographics
NPI:1366496515
Name:CONCANNON, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:CONCANNON
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 1:3115 FALLING LEAF CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-3579
Mailing Address - Country:US
Mailing Address - Phone:573-449-5000
Mailing Address - Fax:573-449-5010
Practice Address - Street 1:3115 FALLING LEAF CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3579
Practice Address - Country:US
Practice Address - Phone:573-449-5000
Practice Address - Fax:573-449-5010
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR7H732086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO289606OtherHEALTHLINK
MO1304006OtherUNITED HEALCARE
MO31925OtherBLUE CHOICE
MO31925OtherBLUE SHIELD
MO289606OtherHEALTHLINK