Healthcare Provider Details

I. General information

NPI: 1376665380
Provider Name (Legal Business Name): MATTHEW D. MINGRONE, MD, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 KNOWLES DR SUITE 121
LOS GATOS CA
95032-1549
US

IV. Provider business mailing address

555 KNOWLES DR SUITE 121
LOS GATOS CA
95032-1549
US

V. Phone/Fax

Practice location:
  • Phone: 408-374-4370
  • Fax: 408-374-8526
Mailing address:
  • Phone: 408-374-4370
  • Fax: 408-374-8526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberA67205
License Number StateCA

VIII. Authorized Official

Name: DR. MATTHEW DOMINIC MINGRONE
Title or Position: CEO
Credential: MD
Phone: 408-374-4370