Provider Demographics
NPI:1245554815
Name:M D M DO LLC
Entity type:Organization
Organization Name:M D M DO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-635-1177
Mailing Address - Street 1:101 MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CASSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65625-1651
Mailing Address - Country:US
Mailing Address - Phone:417-846-2277
Mailing Address - Fax:417-846-0176
Practice Address - Street 1:825 E HIGHWAY 60
Practice Address - Street 2:SUITE H
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-9311
Practice Address - Country:US
Practice Address - Phone:417-635-1177
Practice Address - Fax:417-635-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114771261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263845Medicare Oscar/Certification