Provider Demographics
NPI:1518344753
Name:CHECKETTS, MATTHEW GLEN (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GLEN
Last Name:CHECKETTS
Suffix:
Gender:M
Credentials:DO
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 746093
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6093
Mailing Address - Country:US
Mailing Address - Phone:773-352-1517
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:2850 E MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-9304
Practice Address - Country:US
Practice Address - Phone:480-618-0019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007545207R00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1518344753Medicaid
AZ007545OtherARIZONA OSTEOPATHIC MEDICAL LICENSE