Healthcare Provider Details

I. General information

NPI: 1992899918
Provider Name (Legal Business Name): MATTHEW K. COULSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26538 MOULTON PKWY STE 38E
LAGUNA HILLS CA
92653
US

IV. Provider business mailing address

26538 MOULTON PKWY STE 38E
LAGUNA HILLS CA
92653-8232
US

V. Phone/Fax

Practice location:
  • Phone: 949-448-0656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA92076
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: