Provider Demographics
NPI:1417242074
Name:INGHAM, MATTHEW DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:INGHAM
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 1:15 PARKMAN ST
Mailing Address - Street 2:WANG 528
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3117
Mailing Address - Country:US
Mailing Address - Phone:617-726-2797
Mailing Address - Fax:
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WANG 528
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208800000X208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology