1770503575 NPI number — DR. CLARE M MATNEY M.D.

Table of content: DR. CLARE M MATNEY M.D. (NPI 1770503575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770503575 NPI number — DR. CLARE M MATNEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATNEY
Provider First Name:
CLARE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHERIDAN
Provider Other First Name:
CLARE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770503575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12402 INDUSTRIAL BLVD
Provider Second Line Business Mailing Address:
SUITE B-6
Provider Business Mailing Address City Name:
VICTORVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92395-5871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-780-1237
Provider Business Mailing Address Fax Number:
877-780-3252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12402 INDUSTRIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE B-6
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-5871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-780-1237
Provider Business Practice Location Address Fax Number:
877-780-3252
Provider Enumeration Date:
07/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X , with the licence number:  A42818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0401X , with the licence number: A42818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080C0008X , with the licence number: A42818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083A0300X , with the licence number: A42818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084A0401X , with the licence number: A42818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0802X , with the licence number: A42818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A42818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A428180 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".