Provider Demographics
NPI:1912194150
Name:MAINORD, MATTHEW ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ELLIOTT
Last Name:MAINORD
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 1:5061 ARTESIA DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2433
Mailing Address - Country:US
Mailing Address - Phone:937-384-6800
Mailing Address - Fax:937-384-6939
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6939
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7607573-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine