Provider Demographics
NPI:1932254729
Name:BETTENDORF, MATTHEW J (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:BETTENDORF
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 1:1615 MAPLE LANE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806
Mailing Address - Country:US
Mailing Address - Phone:715-685-5510
Mailing Address - Fax:715-682-4022
Practice Address - Street 1:1615 MAPLE LANE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-685-5510
Practice Address - Fax:715-682-4022
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49280208600000X
WI54097-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932254729Medicaid
MN1932254729Medicaid
MN020002842Medicare PIN
MN1932254729Medicaid