Provider Demographics
NPI:1578635595
Name:WAXTER, MATTHEW S (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:S
Last Name:WAXTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2314
Mailing Address - Country:US
Mailing Address - Phone:503-842-5951
Mailing Address - Fax:503-842-5104
Practice Address - Street 1:312 LAUREL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-2314
Practice Address - Country:US
Practice Address - Phone:503-842-5951
Practice Address - Fax:503-842-5104
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273157111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU71354Medicare UPIN
ORR115554Medicare ID - Type Unspecified