Provider Demographics
NPI:1235576638
Name:TILSTRA, MATTHEW LAURENCE (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LAURENCE
Last Name:TILSTRA
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 1:1552 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3122
Mailing Address - Country:US
Mailing Address - Phone:269-930-0907
Mailing Address - Fax:209-523-2005
Practice Address - Street 1:1552 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3122
Practice Address - Country:US
Practice Address - Phone:209-521-4372
Practice Address - Fax:209-523-2005
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA148079207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology