Healthcare Provider Details

I. General information

NPI: 1255478129
Provider Name (Legal Business Name): MATTHEW M. DO. DPM A PROFFESIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 VICTORIA ST STE 1D
COSTA MESA CA
92627-1906
US

IV. Provider business mailing address

275 VICTORIA ST STE 1D
COSTA MESA CA
92627-1906
US

V. Phone/Fax

Practice location:
  • Phone: 949-645-3338
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3881
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE3881
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3881
License Number StateCA

VIII. Authorized Official

Name: MATTHEW M DO
Title or Position: DOCTOR OF PODIATRIC MEDICINE
Credential: DPM
Phone: 949-645-3338