Provider Demographics
NPI:1073511796
Name:BLUNDELL, MATTHEW CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHARLES
Last Name:BLUNDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 NORTHCREST DR
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-8922
Mailing Address - Country:US
Mailing Address - Phone:707-465-8666
Mailing Address - Fax:707-465-8650
Practice Address - Street 1:1771 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8922
Practice Address - Country:US
Practice Address - Phone:707-465-8666
Practice Address - Fax:707-465-8650
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A626590Medicaid
OR103292OtherNORIDIAN
OR103292OtherNORIDIAN
CA00A626590Medicare PIN