Provider Demographics
NPI:1083901839
Name:CALLAHAN, MATTHEW RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RUSSELL
Last Name:CALLAHAN
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:619-260-7125
Mailing Address - Fax:619-686-3874
Practice Address - Street 1:4077 FIFTH AVE
Practice Address - Street 2:MER 127
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-260-7125
Practice Address - Fax:619-686-3874
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131315207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine