Provider Demographics
NPI:1558621912
Name:YANTIS, MATTHEW GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GREGORY
Last Name:YANTIS
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 1:2944 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1409
Mailing Address - Country:US
Mailing Address - Phone:502-893-0159
Mailing Address - Fax:502-312-3884
Practice Address - Street 1:2944 BRECKENRIDGE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1409
Practice Address - Country:US
Practice Address - Phone:502-893-0159
Practice Address - Fax:502-893-0159
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-20
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078700A207Y00000X
TXBP10044563207Y00000X
KY50401207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100475900Medicaid
IN01078700AOtherLICENSE
KYK240890OtherMEDICARE
IN265400015OtherMEDICARE
KY50401OtherLICENSE