Provider Demographics
NPI:1821062266
Name:BECKERDITE, MATTHEW A (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:BECKERDITE
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 1:2630 STATE HIGHWAY K
Mailing Address - Street 2:STE 100
Mailing Address - City:OFALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:636-240-5454
Mailing Address - Fax:
Practice Address - Street 1:2630 STATE HIGHWAY K
Practice Address - Street 2:STE 100
Practice Address - City:OFALLON
Practice Address - State:MO
Practice Address - Zip Code:63368
Practice Address - Country:US
Practice Address - Phone:636-240-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1821062266Medicaid
MO080185383OtherRAILROAD MEDICARE
MO967675280Medicare PIN
MO080185383OtherRAILROAD MEDICARE