Provider Demographics
NPI:1306289665
Name:WITTRY, MATTHEW JAMES (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:WITTRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 S TOPAZ WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4474
Mailing Address - Country:US
Mailing Address - Phone:208-605-7070
Mailing Address - Fax:
Practice Address - Street 1:7215 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3574
Practice Address - Country:US
Practice Address - Phone:531-999-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18462084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry