Healthcare Provider Details

I. General information

NPI: 1366978199
Provider Name (Legal Business Name): MATTHEW JAMES MAYNARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-2201
US

IV. Provider business mailing address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-2201
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-8570
  • Fax: 916-734-7950
Mailing address:
  • Phone: 916-734-8570
  • Fax: 916-734-7950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS18285
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20A16966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: