Provider Demographics
NPI:1376514638
Name:DIDURO, MATTHEW MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:DIDURO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4104
Mailing Address - Country:US
Mailing Address - Phone:404-402-1903
Mailing Address - Fax:678-909-0659
Practice Address - Street 1:4535 WINTERS CHAPEL RD
Practice Address - Street 2:SUITE B
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30360-2705
Practice Address - Country:US
Practice Address - Phone:678-957-0266
Practice Address - Fax:678-909-0659
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007847111N00000X
NC2134111N00000X
SC1905111N00000X
GACHIR005305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U69320Medicare UPIN
NYBA0598Medicare ID - Type UnspecifiedGROUP NUMBER
NYP010007847OtherEXCELLUSMANAGEDCARE
NYRA7304Medicare ID - Type Unspecified
NYP020007847OtherROCH.BLUESHIELD
NY110777ANOtherPREFERREDCARE
NYG0189954370OtherEXCELLUS GROUP NUMBER