Healthcare Provider Details

I. General information

NPI: 1093927113
Provider Name (Legal Business Name): MATTHEW SALVATORE PUGLIESE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 ST SEBASTIAN WAY STE 104
AUGUSTA GA
30901
US

IV. Provider business mailing address

747 BROADWAY DEPARTMENT OF SURGICAL EDUCATION, 7 WEST
SEATTLE WA
98122
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-0130
  • Fax: 706-434-0131
Mailing address:
  • Phone: 206-386-2123
  • Fax: 206-386-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number062417
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: