Healthcare Provider Details

I. General information

NPI: 1982284345
Provider Name (Legal Business Name): MATTHEW FRY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2021
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 160
SHIPROCK NM
87420-0160
US

IV. Provider business mailing address

405 W GRAND AVE
DAYTON OH
45405-7538
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.016320
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: