Provider Demographics
NPI:1023198884
Name:MATCHETT, MICHAEL JOSEPH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MATCHETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-2524
Mailing Address - Country:US
Mailing Address - Phone:541-821-7862
Mailing Address - Fax:530-841-1930
Practice Address - Street 1:563 N MAIN ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-2524
Practice Address - Country:US
Practice Address - Phone:541-821-7862
Practice Address - Fax:530-841-1930
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3358130172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN00497FMedicaid