Provider Demographics
NPI:1427007293
Name:CLISSOLD, MATTHEW A (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:CLISSOLD
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 1:274 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3915
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:435-753-9521
Practice Address - Street 1:274 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3915
Practice Address - Country:US
Practice Address - Phone:435-753-1600
Practice Address - Fax:435-753-9521
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178712-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870550181001Medicaid
UT870550181001Medicaid