Provider Demographics
NPI:1487646675
Name:BETTAG, MATTHEW EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EDWARD
Last Name:BETTAG
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 1:2424 TREFOIL CT
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-8922
Mailing Address - Country:US
Mailing Address - Phone:920-954-5624
Mailing Address - Fax:
Practice Address - Street 1:1520 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3762
Practice Address - Country:US
Practice Address - Phone:920-734-7181
Practice Address - Fax:920-734-0621
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44145207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34184900Medicaid
WI45014Medicare ID - Type Unspecified
WI34184900Medicaid