Provider Demographics
NPI:1932273349
Name:MATTHIAS, MARK STANLEY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STANLEY
Last Name:MATTHIAS
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 1:1900 CENTRACARE CIRCLE
Mailing Address - Street 2:SUITE 2400
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-229-5099
Mailing Address - Fax:320-229-5171
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:SUITE 2400
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-229-5171
Practice Address - Fax:320-229-5171
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00631764OtherRR MEDICARE
MN413202500Medicaid
MNE49051Medicare UPIN
MNP00631764OtherRR MEDICARE
MN080015505Medicare PIN