Provider Demographics
NPI:1467429977
Name:JOSE, MATHEW M (MD)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:M
Last Name:JOSE
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 1:1015 S BLACKHOOF ST
Mailing Address - Street 2:PO BOX 39
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-2209
Mailing Address - Country:US
Mailing Address - Phone:419-738-3317
Mailing Address - Fax:419-738-5952
Practice Address - Street 1:1015 S BLACKHOOF ST
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-2209
Practice Address - Country:US
Practice Address - Phone:419-738-3317
Practice Address - Fax:419-738-5952
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072597J207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2060915Medicaid
OHP00623951OtherRAILROAD MEDICARE PIN
OHJO4019392Medicare PIN
OH2060915Medicaid