Provider Demographics
NPI:1457348849
Name:MATTHEWS, MARK D (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:MATTHEWS
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 1:101-1 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CASSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65625-1335
Mailing Address - Country:US
Mailing Address - Phone:417-846-2277
Mailing Address - Fax:417-846-0176
Practice Address - Street 1:1011 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1335
Practice Address - Country:US
Practice Address - Phone:417-846-2277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG78690Medicare UPIN