Provider Demographics
NPI:1649210634
Name:LEDERER, MATTHEW Z (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:Z
Last Name:LEDERER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:M
Other - Last Name:LEDERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:650 W RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1254
Mailing Address - Country:US
Mailing Address - Phone:920-882-9662
Mailing Address - Fax:920-882-9912
Practice Address - Street 1:650 W RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1254
Practice Address - Country:US
Practice Address - Phone:920-882-9662
Practice Address - Fax:920-882-9912
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4009-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38962400Medicaid
WI39002500Medicaid
WI753159145012OtherBLUE CROSS BLUE SHIELD GR
WI5594680OtherFIRST HEALTH
WI753159145012OtherBLUE CROSS BLUE SHIELD GR