Provider Demographics
NPI:1285705038
Name:BOOKWALTER, MATTHEW MASON (DPM)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MASON
Last Name:BOOKWALTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7166
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:800 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:503-221-0161
Practice Address - Fax:503-221-4451
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP 00347213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR229013Medicaid
OR229013Medicaid
U97217Medicare UPIN