Healthcare Provider Details

I. General information

NPI: 1417245101
Provider Name (Legal Business Name): MATTHEW FEELEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N WOLFE ST STE WB602
BALTIMORE MD
21205-2103
US

IV. Provider business mailing address

655 COLUMBIA ST UNIT 208
SAN DIEGO CA
92101-6744
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-3630
  • Fax:
Mailing address:
  • Phone: 808-777-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number152340
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT200277
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC152340
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: