Provider Demographics
NPI:1992794945
Name:MOOG, MATTHEW REASE (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:REASE
Last Name:MOOG
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:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:BIG HORN
Mailing Address - State:WY
Mailing Address - Zip Code:82833-0514
Mailing Address - Country:US
Mailing Address - Phone:406-599-9561
Mailing Address - Fax:
Practice Address - Street 1:1401 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2705
Practice Address - Country:US
Practice Address - Phone:307-672-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9615207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0027506Medicaid
ID805495000Medicaid
MT0027506Medicaid
G74893Medicare UPIN