Provider Demographics
NPI:1841228814
Name:JOHN, MATTHEW WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WADE
Last Name:JOHN
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 1:5501 NW 62ND TER STE 100
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-2412
Mailing Address - Country:US
Mailing Address - Phone:816-842-4440
Mailing Address - Fax:816-842-1974
Practice Address - Street 1:3601 NE RALPH POWELL RD STE C
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-2316
Practice Address - Country:US
Practice Address - Phone:816-285-5053
Practice Address - Fax:816-842-1974
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009007994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1841228814Medicaid
F88000011Medicare PIN
MOY36000033Medicare PIN