Healthcare Provider Details

I. General information

NPI: 1932634045
Provider Name (Legal Business Name): MATTHEW REZA FOLLANSBEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

IV. Provider business mailing address

401 BICENTENNIAL WAY # 2
SANTA ROSA CA
95403-2149
US

V. Phone/Fax

Practice location:
  • Phone: 707-393-4187
  • Fax:
Mailing address:
  • Phone: 805-569-7315
  • Fax: 805-569-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA159794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: