Provider Demographics
NPI:1306967377
Name:SELF, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SELF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LARKSPUR CT
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-6913
Mailing Address - Country:US
Mailing Address - Phone:479-967-3009
Mailing Address - Fax:
Practice Address - Street 1:200 N 3RD ST
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-3802
Practice Address - Country:US
Practice Address - Phone:479-229-2827
Practice Address - Fax:479-229-6167
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine