Provider Demographics
NPI:1679521835
Name:BURRELL, MATTHEW L (DPM)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:BURRELL
Suffix:
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 1:144 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-1240
Mailing Address - Country:US
Mailing Address - Phone:603-536-4563
Mailing Address - Fax:603-536-1056
Practice Address - Street 1:144 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1240
Practice Address - Country:US
Practice Address - Phone:603-536-4563
Practice Address - Fax:603-536-1056
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD 1026213E00000X
NH287213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH03Y003885ME01OtherANTHEM
NH30362275Medicaid
ME03Z003885ME01OtherANTHEM
1301419OtherCIGNA
ME188430000Medicaid
NH30362275Medicaid
NHRE7119Medicare PIN
ME188430000Medicaid