Provider Demographics
NPI:1154311058
Name:MATTHEIS, JAY KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:KENNETH
Last Name:MATTHEIS
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 1:11370 ANDERSON ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2154
Mailing Address - Fax:909-558-2180
Practice Address - Street 1:11370 ANDERSON ST STE 1800
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2154
Practice Address - Fax:909-558-2180
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56477207W00000X
NV14270207W00000X
CAG66270207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100527518Medicaid
NVP01074697OtherRR MEDICARE PTAN
NV1801843685OtherGROUP NPI#
NV1801843685OtherGROUP NPI#
NVBM3243502OtherDEA
NV1801843685OtherGROUP NPI#