Provider Demographics
NPI:1932469335
Name:SNODGRASS, MATHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:SNODGRASS
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6337
Practice Address - Country:US
Practice Address - Phone:541-706-4800
Practice Address - Fax:541-706-4806
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG158934390200000X
ORMD168036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR175790Medicare PIN
ORR175789Medicare PIN
ORR175787Medicare PIN
ORR175784Medicare PIN
ORR175786Medicare PIN
ORR175788Medicare PIN