Provider Demographics
NPI:1376546424
Name:VANDER WOUDE, MATTHEW T (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:T
Last Name:VANDER WOUDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 MCCANN RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7842
Mailing Address - Country:US
Mailing Address - Phone:903-753-1212
Mailing Address - Fax:
Practice Address - Street 1:3111 MCCANN RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7842
Practice Address - Country:US
Practice Address - Phone:903-753-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1942207P00000X
NV934207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV201875024Medicaid
NV38994Medicare ID - Type Unspecified