Provider Demographics
NPI:1720039704
Name:KINGSBAUER, MATTHEW B (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:B
Last Name:KINGSBAUER
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 1:215 STRATTON RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4621
Mailing Address - Country:US
Mailing Address - Phone:802-855-2027
Mailing Address - Fax:802-855-2053
Practice Address - Street 1:215 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-773-3386
Practice Address - Fax:802-773-4578
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO000001622207Q00000X
VT032-0072647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1018489Medicaid
VT1018489Medicaid
TNI15941Medicare UPIN
TN202991771OtherAETNA
VTY400147006Medicare PIN
TN202991771OtherHUMANA
TN202991771OtherUNITED HEALTH CARE
TN202991771OtherCCN
TN202991771OtherCONTINENTAL LIFE
TN202991771OtherBENEFIT PLANNERS
TN202991771OtherAARP
VT1018489Medicaid
202991771OtherNGS
TN202991771OtherPRINCIPAL LIFE INS.
TN202991771OtherCOMPREHENSVIE BENEFITS
8531484OtherCIGNA
002030701Medicare PIN
114166OtherHEALTH PARTNERS
TN202991771OtherGREAT WEST HEALTHCARE
TN3897631Medicare ID - Type UnspecifiedMEDICARE
TN3731172Medicaid
TN4125380OtherBCBST