Provider Demographics
NPI:1245623149
Name:MIVSEK, MATTHEW JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:MIVSEK
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 1:231 SEASONS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44224
Mailing Address - Country:US
Mailing Address - Phone:330-662-5666
Mailing Address - Fax:330-655-3845
Practice Address - Street 1:231 SEASONS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44224
Practice Address - Country:US
Practice Address - Phone:330-662-5666
Practice Address - Fax:330-655-3845
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0230659Medicaid