Healthcare Provider Details

I. General information

NPI: 1003179193
Provider Name (Legal Business Name): MATTHEW S SPIVA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number8718615-0501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number8718615-0501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD387
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD387
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: