Provider Demographics
NPI:1811020969
Name:HERBST, MATHEW PATRICK (MD)
Entity Type:Individual
Prefix:MR
First Name:MATHEW
Middle Name:PATRICK
Last Name:HERBST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1100 DELAPLAINE CT
Mailing Address - Street 2:ATTN: EDUCATIONAL SERVICES
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 S CENTURY AVE
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597
Practice Address - Country:US
Practice Address - Phone:608-849-4315
Practice Address - Fax:608-850-1606
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI66597-20207Q00000X
WI10762-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811020969Medicaid