Provider Demographics
NPI:1649412578
Name:STOVER, MATTHEW DAVID (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:STOVER
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 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:610 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1251
Practice Address - Country:US
Practice Address - Phone:304-766-7515
Practice Address - Fax:304-766-7566
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102-203771207X00000X
WV2970207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVE167AOtherMEDICARE PTAN
WV3810029502Medicaid
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP WV MEDICAID
VAVVE167BOtherMEDICARE PTAN
WV3810029502Medicaid