Provider Demographics
NPI:1295919876
Name:VIBBERT, MATTHEW DALLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DALLAS
Last Name:VIBBERT
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 1:909 WALNUT STREET
Mailing Address - Street 2:COB, 2ND FLR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:215-955-7000
Mailing Address - Fax:215-503-7007
Practice Address - Street 1:909 WALNUT STREET
Practice Address - Street 2:COB, 2ND FLR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-7000
Practice Address - Fax:215-503-7007
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4405822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0199915Medicaid
PA102501633Medicaid
PA190347Medicare PIN