Provider Demographics
NPI:1477550762
Name:VONMATTHIESSEN, PAMELA WAGNER (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:WAGNER
Last Name:VONMATTHIESSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 LIVERMORE STREET
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387
Mailing Address - Country:US
Mailing Address - Phone:937-767-0147
Mailing Address - Fax:970-641-9017
Practice Address - Street 1:1234 LIVERMORE STREET
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387
Practice Address - Country:US
Practice Address - Phone:937-767-0147
Practice Address - Fax:970-641-9017
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38431207R00000X
OH35.076986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2208659Medicaid
CO70076341Medicaid
OH2208659Medicaid
CO70076341Medicaid