Provider Demographics
NPI:1417272063
Name:MUTTER, MATTHEW JUDE (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JUDE
Last Name:MUTTER
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 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-7302
Mailing Address - Fax:
Practice Address - Street 1:880 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-545-6969
Practice Address - Fax:901-545-7260
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN52976208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program