Healthcare Provider Details

I. General information

NPI: 1467608794
Provider Name (Legal Business Name): MATHEW SHADIOW CRT, ARRT, CA FLUORO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 WILLOW RD
MENLO PARK CA
94025-2617
US

IV. Provider business mailing address

PO BOX 612855
SAN JOSE CA
95161-2855
US

V. Phone/Fax

Practice location:
  • Phone: 650-324-8500
  • Fax:
Mailing address:
  • Phone: 408-829-2235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberRHF 74300
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberARRT313398
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: