Basic Information
| Provider Information | |||||||||
| NPI: | 1053574392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 CAMPUS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405365100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | |||||||||
| City: | BERKELEY SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254117463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042586981 | ||||||||
| FaxNumber: | 3042580508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2008 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | 0103301039 | VA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213EP1101X | 02207 | WV | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1053574392 | 05 | WV | MEDICAID |