Healthcare Provider Details

I. General information

NPI: 1700409133
Provider Name (Legal Business Name): MATTHEW JACOB NAGELSCHMIDT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 PORTLAND AVE STE 210
ROCHESTER NY
14621-3008
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-266-2010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number324015
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: