Provider Demographics
NPI:1992996458
Name:MATAVERDE, PHILIP ALEXANDER (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALEXANDER
Last Name:MATAVERDE
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 1:3200 W CENTRE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 W CENTRE AVE STE 203
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4889
Practice Address - Country:US
Practice Address - Phone:269-349-9745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL18658582084N0400X
MO20120207022084N0400X, 2084S0012X
MI5101017269207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01092598OtherRAILROAD MEDICARE PTAN
MO1992996458Medicaid
MOP01092598OtherRAILROAD MEDICARE PTAN