MEDICARE: MATTHEW KORNSWIET

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	2080S0010X	Pediatric Sports Medicine Physician	20A17197	CA
2	208000000X	Pediatrics Physician	20A17197	CA

General Provider Information

NPI Number	:	1336534338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW KORNSWIET

Provider Business Mailing Address
First Line	:	23521 PASEO DE VALENCIA STE 200
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-3101
Country	:	US
Telephone Number	:	949-951-5437
Fax Number	:

Provider Business Practice Location Address
First Line	:	23521 PASEO DE VALENCIA STE 200
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-3101
Country	:	US
Telephone Number	:	949-951-5437
Fax Number	:

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

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	06/19/2019

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Directions to “ MATTHEW KORNSWIET ” Practice Location

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