Healthcare Provider Details

I. General information

NPI: 1457474892
Provider Name (Legal Business Name): MATTHEW CHARLES GUMMERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 7TH AVE
FORT WORTH TX
76104-2733
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-4054
  • Fax: 682-885-7497
Mailing address:
  • Phone: 683-885-6483
  • Fax: 682-885-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberN7271
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number7335
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number0101240998
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: