Provider Demographics
NPI:1649461625
Name:SHAFFER, MATTHEW JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:SHAFFER
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:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:2201 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2843
Practice Address - Country:US
Practice Address - Phone:606-408-6200
Practice Address - Fax:606-408-6825
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV22835207Q00000X
KY44465208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3159764Medicaid
KY7100156550Medicaid
KYP400040133Medicare PIN