Provider Demographics
NPI:1417996935
Name:O'BRIEN, MATTHEW MAXIMILIAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MAXIMILIAN
Last Name:O'BRIEN
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 1:1401 FOULK RD
Mailing Address - Street 2:STE 202
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-2763
Mailing Address - Country:US
Mailing Address - Phone:302-478-5650
Mailing Address - Fax:302-477-0455
Practice Address - Street 1:1401 FOULK RD
Practice Address - Street 2:STE 202
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-2763
Practice Address - Country:US
Practice Address - Phone:302-478-5650
Practice Address - Fax:302-477-0455
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG02363B01OtherMEDICARE PTAN
G01415Medicare ID - Type Unspecified
H23524Medicare UPIN