Provider Demographics
NPI:1700888617
Name:SHAMBAUGH, MATTHEW E (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:E
Last Name:SHAMBAUGH
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 1:7920 W JEFFERSON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4166
Mailing Address - Country:US
Mailing Address - Phone:260-490-7111
Mailing Address - Fax:260-490-2286
Practice Address - Street 1:7920 W JEFFERSON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4166
Practice Address - Country:US
Practice Address - Phone:260-490-7111
Practice Address - Fax:260-490-2286
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038077A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN240007527OtherMEDICARE RAILROAD
MI104366811Medicaid
OH0852733Medicaid
IN100372030Medicaid
IN186080FMedicare PIN
IN240007527Medicare PIN
IN100372030Medicaid