MEDICARE: MR. MATTHEW HART

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1508417510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW HART

Provider Business Mailing Address
First Line	:	6829 GA HIGHWAY 17 S
Second Line	:
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-4610
Country	:	US
Telephone Number	:	912-547-4013
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 BOB WILSON DRIVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92134-0001
Country	:	US
Telephone Number	:	912-547-4013
Fax Number	:

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

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	09/23/2019

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Directions to “ MR. MATTHEW HART ” Practice Location

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