Provider Demographics
NPI:1497723613
Name:HIESTAND, MATTHEW E (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:E
Last Name:HIESTAND
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 1:6046 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7616
Mailing Address - Country:US
Mailing Address - Phone:330-874-7165
Mailing Address - Fax:330-874-7166
Practice Address - Street 1:10724 STATE ROUTE 212 NE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:OH
Practice Address - Zip Code:44612-8740
Practice Address - Country:US
Practice Address - Phone:330-874-7165
Practice Address - Fax:330-874-7166
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070029H207R00000X
OH35-070029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2066473Medicaid
G62873Medicare UPIN
OHHI0840841Medicare PIN