Provider Demographics
NPI:1942437652
Name:MISSERT, MATTHEW JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:MISSERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2648
Mailing Address - Country:US
Mailing Address - Phone:716-862-1420
Mailing Address - Fax:
Practice Address - Street 1:2157 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2648
Practice Address - Country:US
Practice Address - Phone:716-862-1420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY265123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program