MEDICARE: MATTHEW CHARLES BLUNDELL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A62659	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	103292	OTHER	OR	NORIDIAN

General Provider Information

NPI Number	:	1073511796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW CHARLES BLUNDELL MD

Provider Business Mailing Address
First Line	:	1771 NORTHCREST DR
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-8922
Country	:	US
Telephone Number	:	707-465-8666
Fax Number	:	707-465-8650

Provider Business Practice Location Address
First Line	:	1771 NORTHCREST DR
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-8922
Country	:	US
Telephone Number	:	707-465-8666
Fax Number	:	707-465-8650

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	09/13/2012

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