Healthcare Provider Details

I. General information

NPI: 1336534338
Provider Name (Legal Business Name): MATTHEW KORNSWIET
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23521 PASEO DE VALENCIA STE 200
LAGUNA HILLS CA
92653-3101
US

IV. Provider business mailing address

23521 PASEO DE VALENCIA STE 200
LAGUNA HILLS CA
92653-3101
US

V. Phone/Fax

Practice location:
  • Phone: 949-951-5437
  • Fax:
Mailing address:
  • Phone: 949-951-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number20A17197
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A17197
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: