Provider Demographics
NPI:1205225174
Name:HADILAKSONO, MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:HADILAKSONO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 LA COLIMA
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2841
Mailing Address - Country:US
Mailing Address - Phone:310-500-7966
Mailing Address - Fax:
Practice Address - Street 1:1105 LAS TABLAS RD STE D
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9731
Practice Address - Country:US
Practice Address - Phone:805-550-6689
Practice Address - Fax:833-615-2271
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A154702081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine