Provider Demographics
NPI:1164895322
Name:OLDHAM, MATTHEW ALEXANDER (IDC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:OLDHAM
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 561 BOX 1877
Mailing Address - Street 2:BLDG #111
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0019
Mailing Address - Country:US
Mailing Address - Phone:0803-002-3769
Mailing Address - Fax:
Practice Address - Street 1:PSC 561 BOX 1877
Practice Address - Street 2:BLDG #111
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96310-0019
Practice Address - Country:US
Practice Address - Phone:0803-002-3769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman