Provider Demographics
NPI:1376705533
Name:OUGH, MATTHEW J (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:OUGH
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 1:720 S VANBUREN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3534
Mailing Address - Country:US
Mailing Address - Phone:920-433-7488
Mailing Address - Fax:
Practice Address - Street 1:720 S VANBUREN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3534
Practice Address - Country:US
Practice Address - Phone:920-433-7488
Practice Address - Fax:920-433-7439
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55920-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI025000215Medicare Oscar/Certification
WI030280044Medicare Oscar/Certification