Provider Demographics
NPI:1861621633
Name:PITTMAN, MATTHEW R (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:R
Last Name:PITTMAN
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 1:351 DELNOR DR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4222
Mailing Address - Country:US
Mailing Address - Phone:630-668-0833
Mailing Address - Fax:630-667-7685
Practice Address - Street 1:4830 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:SUITE J
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2300
Practice Address - Country:US
Practice Address - Phone:614-293-3230
Practice Address - Fax:614-293-4030
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.055834208600000X
OH35123279208600000X
IL036138487208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0104249Medicaid
IL206147OtherMEDICARE PTAN GROUP
ILF400237729OtherMEDICARE PTAN INDIVIDUAL
IL206147OtherMEDICARE PTAN GROUP