Healthcare Provider Details

I. General information

NPI: 1346232790
Provider Name (Legal Business Name): MATTHEW CHARLES KIDD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2005
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2238 PASEO DEL REY ST
NEEDLES CA
92363-3520
US

IV. Provider business mailing address

2238 PASEO DEL REY ST
NEEDLES CA
92363-3520
US

V. Phone/Fax

Practice location:
  • Phone: 760-326-2340
  • Fax: 760-326-2340
Mailing address:
  • Phone: 760-326-2340
  • Fax: 760-326-2340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberG37237
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: