Healthcare Provider Details

I. General information

NPI: 1891784203
Provider Name (Legal Business Name): MATTHEW JOSEPH BARULICH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 SOUTH AVE
SOUTH LAKE TAHOE CA
96150-7026
US

IV. Provider business mailing address

PO BOX 2046
CARSON CITY NV
89702-2046
US

V. Phone/Fax

Practice location:
  • Phone: 775-882-8487
  • Fax: 775-882-8487
Mailing address:
  • Phone: 775-882-8487
  • Fax: 775-882-8487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5413
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA40451
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: