Healthcare Provider Details

I. General information

NPI: 1487098984
Provider Name (Legal Business Name): MATTHEW DAVID SOUSTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6670 ALTON PARKWAY
IRVINE CA
92618
US

IV. Provider business mailing address

200-10531-117TH ST. N.W
EDMONTON ALBERTA
T5H0A8
CA

V. Phone/Fax

Practice location:
  • Phone: 949-932-5002
  • Fax:
Mailing address:
  • Phone: 780-862-6107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA124807
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: