Provider Demographics
NPI:1346232790
Name:KIDD, MATTHEW CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHARLES
Last Name:KIDD
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 1:2238 PASEO DEL REY ST
Mailing Address - Street 2:
Mailing Address - City:NEEDLES
Mailing Address - State:CA
Mailing Address - Zip Code:92363-3520
Mailing Address - Country:US
Mailing Address - Phone:760-326-2340
Mailing Address - Fax:760-326-2340
Practice Address - Street 1:2238 PASEO DEL REY ST
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3520
Practice Address - Country:US
Practice Address - Phone:760-326-2340
Practice Address - Fax:760-326-2340
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-20
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG372372083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ185307-02Medicaid
CAG372370OtherBLUE SHIELD OF CA
TRAVELERSOther00G372370
CA00G372370Medicaid
CAC379870OtherBLUE CROSS OF CA
CA00G372370Medicaid
CA00G372370Medicare ID - Type Unspecified