Provider Demographics
NPI:1750345690
Name:DEETHS, MATTHEW J (MD PHD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:DEETHS
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 LITTLE BOOKCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8801
Mailing Address - Country:US
Mailing Address - Phone:970-242-7273
Mailing Address - Fax:970-241-2878
Practice Address - Street 1:2655 LITTLE BOOKCLIFF DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8801
Practice Address - Country:US
Practice Address - Phone:970-242-7273
Practice Address - Fax:970-241-2878
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42346207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04271556Medicaid
CO04271556Medicaid
CO535768Medicare PIN