Provider Demographics
NPI:1801390190
Name:MOYNIHAN, MATTHEW THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:MOYNIHAN
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 1:856 N FRANCISCO AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4458
Mailing Address - Country:US
Mailing Address - Phone:630-201-2607
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.154950207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.154950OtherILLINOIS STATE MEDICAL LICENSE
IL336.119004OtherILLINOIS CONTROLLED SUBSTANCE LICENSE