Provider Demographics
NPI:1639143688
Name:MATUSHIN, CLIFFORD M (DO)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:M
Last Name:MATUSHIN
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 1:919 NORTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-2172
Mailing Address - Country:US
Mailing Address - Phone:763-389-3344
Mailing Address - Fax:
Practice Address - Street 1:919 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2172
Practice Address - Country:US
Practice Address - Phone:763-389-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3575207R00000X
MN107306207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6002770Medicaid
MN107306OtherMINNESOTA LICENSE
SD3575OtherSTATE LICENSE
SD6002770Medicaid
SDF28475Medicare UPIN