Healthcare Provider Details

I. General information

NPI: 1215673090
Provider Name (Legal Business Name): MATTHEW SGOUROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 23RD AVE S STE 200
FARGO ND
58104-9138
US

IV. Provider business mailing address

1755 PARK BLVD S
FARGO ND
58103-4733
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-4112
  • Fax:
Mailing address:
  • Phone: 914-588-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0116036260
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: