Healthcare Provider Details

I. General information

NPI: 1124412275
Provider Name (Legal Business Name): MATTHEW BLAKE WARREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 RIVERWALK PKWY STE 230
RIVERSIDE CA
92505-3312
US

IV. Provider business mailing address

PO BOX 60219
IRVINE CA
92602-6007
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-3672
  • Fax:
Mailing address:
  • Phone: 951-781-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA170797
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA170797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: