Provider Demographics
NPI:1710199021
Name:CARR, MATTHEW DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:CARR
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 1:602 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4918
Mailing Address - Country:US
Mailing Address - Phone:616-394-3185
Mailing Address - Fax:616-494-4003
Practice Address - Street 1:602 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4918
Practice Address - Country:US
Practice Address - Phone:616-394-3185
Practice Address - Fax:616-494-4003
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098138207ZP0102X, 207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200859920Medicaid
I73433OtherUPIN
IN11-00719OtherMEDICA
IN000000525386OtherANTHEM
INP00402867OtherRR MEDICARE
IN679170XXMedicare PIN