Provider Demographics
NPI:1922070093
Name:ANDERSEN, MATTHEW TODD (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TODD
Last Name:ANDERSEN
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 1:11760 S 700 E
Mailing Address - Street 2:STE 111
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6604
Mailing Address - Country:US
Mailing Address - Phone:801-576-8855
Mailing Address - Fax:
Practice Address - Street 1:11760 S 700 E
Practice Address - Street 2:STE 111
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6604
Practice Address - Country:US
Practice Address - Phone:801-576-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT54148941205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine