Provider Demographics
NPI:1649401829
Name:MISKIMON, MATTHEW (MD, PHD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:MISKIMON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 POWDER VIEW CT
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4796
Mailing Address - Country:US
Mailing Address - Phone:410-530-7327
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-7300
Practice Address - Fax:212-263-7002
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA260998207P00000X
PAMD451632207P00000X
NH18809207P00000X
MI4301104712207P00000X
NJ25MA09507700207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0550361Medicaid