Provider Demographics
NPI:1659378750
Name:DEMORE, MATTHEW III (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:DEMORE
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-538-0040
Mailing Address - Fax:912-538-7070
Practice Address - Street 1:1707 MEADOWS LN STE H
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7201
Practice Address - Country:US
Practice Address - Phone:912-538-0040
Practice Address - Fax:912-538-7070
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-002649D213ES0103X
GAPOD001325213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU18427Medicare UPIN
OHCH5179OtherRR MEDICARE GROUP # CFAC
OHCI5538OtherRR MEDICARE GROUP # BFAC
OH0868549Medicare PIN
OH480034448OtherRR MEDICARE BFAC
OH1131510004Medicare NSC
OH0868548Medicare PIN
OH480035039OtherRR MEDICARE CFAC
OHU18427Medicare UPIN
OH0880711Medicaid
OH480035039OtherRR MEDICARE CFAC
OHU18427Medicare UPIN
OH0880711Medicaid