Provider Demographics
NPI:1609876507
Name:SMITH, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2818
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2818
Mailing Address - Country:US
Mailing Address - Phone:319-235-3568
Mailing Address - Fax:319-235-5013
Practice Address - Street 1:1753 W RIDGEWAY AVE STE 103A
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4521
Practice Address - Country:US
Practice Address - Phone:319-235-3568
Practice Address - Fax:319-235-5013
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA34208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA5212415Medicaid
H40517Medicare UPIN
IA5212415Medicaid