Healthcare Provider Details

I. General information

NPI: 1104088731
Provider Name (Legal Business Name): MATTHEW C RALSTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 DUBOIS DR
WARSAW IN
46580-3212
US

IV. Provider business mailing address

2251 DUBOIS DR
WARSAW IN
46580-3212
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-2777
  • Fax:
Mailing address:
  • Phone: 574-269-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number11013941A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: