Provider Demographics
NPI:1649263633
Name:MATISOFF, DAVID N (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:N
Last Name:MATISOFF
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3960 PATIENT CARE DR
Practice Address - Street 2:SUITE 113
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4275
Practice Address - Country:US
Practice Address - Phone:517-484-0004
Practice Address - Fax:517-484-7241
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDM0400012080P0202X
MI43010400012080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350C31064OtherBLUE CROSS BLUE SHIELD
MI7500132OtherPHP
MIL3338302Medicaid
MI40155OtherBLUE CARE NETWORK
MI40155OtherBLUE CARE NETWORK