Provider Demographics
NPI:1366637555
Name:MISNER, MATTHEW R (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:MISNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:ROBERT
Other - Last Name:HANNASCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:213 MIDDLEBURY ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-2956
Mailing Address - Country:US
Mailing Address - Phone:574-534-3300
Mailing Address - Fax:574-534-5412
Practice Address - Street 1:213 MIDDLEBURY ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528
Practice Address - Country:US
Practice Address - Phone:574-534-3300
Practice Address - Fax:574-534-5412
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11818208000000X
VA0102205035208000000X
OK4644208000000X
IN02004768A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300019274Medicaid
IN236040293OtherMEDICARE PTAN