Provider Demographics
NPI:1649271610
Name:DEROSIER, MATTHEW RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RICHARD
Last Name:DEROSIER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1973
Mailing Address - Country:US
Mailing Address - Phone:701-222-2252
Mailing Address - Fax:701-222-3645
Practice Address - Street 1:1921 N 13TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1973
Practice Address - Country:US
Practice Address - Phone:701-222-2252
Practice Address - Fax:701-222-3645
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3957111N00000X
ND799111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44-88343OtherMEDICA
ND10761Medicaid
MN49M33DEOtherBCBS - MN
ND30063OtherBCBSND
MN350054947OtherRAILROAD MEDICARE
MN92363OtherHEALTHPARTNERS
MN92363OtherHEALTHPARTNERS
MN350054947OtherRAILROAD MEDICARE