Provider Demographics
NPI:1275811739
Name:SHADIS, MATTHEW ALAN
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALAN
Last Name:SHADIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 CERRILLOS ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-438-8488
Mailing Address - Fax:505-438-6011
Practice Address - Street 1:2325 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3373
Practice Address - Country:US
Practice Address - Phone:505-438-0010
Practice Address - Fax:505-438-6011
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator