Provider Demographics
NPI:1821032152
Name:SMITH, MATTHEW BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRADLEY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:BRADLEY
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:122 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-1266
Mailing Address - Country:US
Mailing Address - Phone:740-694-1261
Mailing Address - Fax:740-694-7145
Practice Address - Street 1:122 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:OH
Practice Address - Zip Code:43019-1266
Practice Address - Country:US
Practice Address - Phone:740-694-1261
Practice Address - Fax:740-694-7145
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.080703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2327520Medicaid
OH000000228476OtherANTHEM BC/BS
OH2236399OtherUNITED HEALTHCARE OF OHIO
OH4083463Medicare PIN
OH2327520Medicaid