Provider Demographics
NPI:1871773168
Name:SPERRY, MATTHEW BLACK (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BLACK
Last Name:SPERRY
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 1:4605 W 10600 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9553
Mailing Address - Country:US
Mailing Address - Phone:801-763-0549
Mailing Address - Fax:
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:SUITE 500
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-357-7291
Practice Address - Fax:801-357-7919
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115860207R00000X
UT7250922-1205207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine