Provider Demographics
NPI:1679916977
Name:FANOUS, MATTHEW JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:FANOUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-392-3400
Mailing Address - Fax:
Practice Address - Street 1:597 EXECUTIVE CAMPUS DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8870
Practice Address - Country:US
Practice Address - Phone:614-392-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNONE ASSIGNED207R00000X
OH35128375208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine