Healthcare Provider Details

I. General information

NPI: 1376514638
Provider Name (Legal Business Name): MATTHEW MICHAEL DIDURO D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 WINTERS CHAPEL RD SUITE B
DORAVILLE GA
30360-2705
US

IV. Provider business mailing address

766 FAIRFIELD DR
MARIETTA GA
30068-4104
US

V. Phone/Fax

Practice location:
  • Phone: 678-957-0266
  • Fax: 678-909-0659
Mailing address:
  • Phone: 404-402-1903
  • Fax: 678-909-0659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX007847
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2134
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1905
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR005305
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: