MEDICARE: MATTHEW DAVID TADLOCK 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	2083A0100X	Aerospace Medicine Physician	01058634A	IN
2	2086S0102X	Surgical Critical Care Physician	C54740	CA

General Provider Information

NPI Number	:	1881666956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW DAVID TADLOCK MD

Provider Business Mailing Address
First Line	:	PO BOX 232410
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92193-2410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 W ARBOR DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-9000
Country	:	US
Telephone Number	:	800-926-8273
Fax Number	:	619-532-6299

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	09/22/2020

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