Provider Demographics
NPI:1750339610
Name:PROUDFOOT, MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PROUDFOOT
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 1:1801 JASON CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-3639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-593-1573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011974207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00286332Medicare ID - Type UnspecifiedRAILROAD
MIG52394Medicare UPIN
MIP00286332Medicare PIN