Healthcare Provider Details

I. General information

NPI: 1780656694
Provider Name (Legal Business Name): MATTHEW JOHN WAUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR SUITE 308 NEPHROLOGY DIVISION
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

34800 BOB WILSON DR SUITE 308 NEPHROLOGY DIVISION
SAN DIEGO CA
92134-5000
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-8840
  • Fax: 619-532-7178
Mailing address:
  • Phone: 619-532-8840
  • Fax: 619-532-7178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number200100622
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: