Healthcare Provider Details

I. General information

NPI: 1477130896
Provider Name (Legal Business Name): MATTHEW PETER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CUMMINGS CTR STE 309V
BEVERLY MA
01915-6181
US

IV. Provider business mailing address

900 CUMMINGS CTR STE 309V
BEVERLY MA
01915-6181
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-0288
  • Fax: 978-927-6265
Mailing address:
  • Phone: 978-922-0288
  • Fax: 978-927-6265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number2553
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: