Provider Demographics
NPI:1639602956
Name:GANGIDINE, MATTHEW MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MARTIN
Last Name:GANGIDINE
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 1:5955 ZEAMER AVE
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE ELMENDORF-RICHARDSON
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:907-580-6648
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:
Practice Address - City:JOINT BASE ELMENDORF-RICHARDSON
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-5556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0064416207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services