Healthcare Provider Details

I. General information

NPI: 1548521719
Provider Name (Legal Business Name): MATTHEW J ALLRED D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CTR 34800 BOB WILSON DRIVE
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7082
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1065
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number74247
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: