Provider Demographics
NPI:1164540456
Name:WERNER, MATTHEW L (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:WERNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47250 WASHINGTON ST
Mailing Address - Street 2:A
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2105
Mailing Address - Country:US
Mailing Address - Phone:760-771-9437
Mailing Address - Fax:760-564-8581
Practice Address - Street 1:47250 WASHINGTON ST
Practice Address - Street 2:A
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2105
Practice Address - Country:US
Practice Address - Phone:760-771-9437
Practice Address - Fax:760-564-8581
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG079952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071340Medicaid
CA00G799520Medicare ID - Type Unspecified
CAGR0071340Medicaid