Healthcare Provider Details

I. General information

NPI: 1376749069
Provider Name (Legal Business Name): MATTHEW ALEXANDER HUMPHREYS SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

332 A AVE
CORONADO CA
92118-1914
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7935
  • Fax: 619-532-7617
Mailing address:
  • Phone: 619-417-1168
  • Fax: 619-532-7617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA105928
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberA105928
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: