Provider Demographics
NPI:1437492816
Name:GESTAUT, MATTHEW MAXWELL (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MAXWELL
Last Name:GESTAUT
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 1:3053 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-968-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN568412085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044082Medicaid