Provider Demographics
NPI:1205935848
Name:STETTER, MATTHEW A (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:STETTER
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 1:1120 E WAR MEMORIAL
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616
Mailing Address - Country:US
Mailing Address - Phone:309-685-0100
Mailing Address - Fax:309-685-0172
Practice Address - Street 1:621 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550
Practice Address - Country:US
Practice Address - Phone:309-263-4343
Practice Address - Fax:309-263-1363
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL82755OtherPIN
ILH13953Medicare UPIN
IL445080Medicare ID - Type UnspecifiedFACILITY MEDICARE ID