Provider Demographics
NPI:1881633162
Name:BENDER, MATTHEW M (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:M
Last Name:BENDER
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 1:6052 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2739
Mailing Address - Country:US
Mailing Address - Phone:208-947-1947
Mailing Address - Fax:208-947-1945
Practice Address - Street 1:6052 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2739
Practice Address - Country:US
Practice Address - Phone:208-947-1947
Practice Address - Fax:208-947-1945
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9026207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806939200Medicaid
H93222Medicare UPIN
ID1124956Medicare PIN