Provider Demographics
NPI:1457318503
Name:MARCHAL, MATTHEW WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WALTER
Last Name:MARCHAL
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:PO BOX 934915
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-4915
Mailing Address - Country:US
Mailing Address - Phone:404-501-7969
Mailing Address - Fax:
Practice Address - Street 1:200 E PONCE DE LEON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3466
Practice Address - Country:US
Practice Address - Phone:404-501-6363
Practice Address - Fax:404-371-0019
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058012207Q00000X
GA070678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003139521AMedicaid
00V911A02Medicare ID - Type UnspecifiedMEDICARE
P00166136Medicare ID - Type UnspecifiedMEDICARE RAILROAD
C09044Medicare ID - Type UnspecifiedMEDICARE OFFICE
G74009Medicare UPIN