Basic Information
| Provider Information | |||||||||
| NPI: | 1609135375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPAL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | RANDAL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S ILLINOIS AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504015489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414283041 | ||||||||
| FaxNumber: | 7122643509 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH SIOUX CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687761703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024943064 | ||||||||
| FaxNumber: | 7122947299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2012 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-42604 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 47068731712 | 05 | NE | MEDICAID |