Provider Demographics
NPI:1285747477
Name:GANGWER, MATTHEW MORGAN (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MORGAN
Last Name:GANGWER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MIDWAY ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1706
Mailing Address - Country:US
Mailing Address - Phone:423-968-5225
Mailing Address - Fax:423-968-1223
Practice Address - Street 1:28 MIDWAY ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1706
Practice Address - Country:US
Practice Address - Phone:423-968-5225
Practice Address - Fax:423-968-1223
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN19556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNE93892Medicare UPIN
3043704Medicare ID - Type Unspecified