Provider Demographics
NPI:1376048298
Name:FALLER, MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:FALLER
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:NAVAL MEDICAL CENTER SAN DIEGO 38400 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:618-979-1561
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:618-979-1561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101267548207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program