Provider Demographics
NPI:1376749069
Name:HUMPHREYS, MATTHEW ALEXANDER SR (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:HUMPHREYS
Suffix:SR
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 1:332 A AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1914
Mailing Address - Country:US
Mailing Address - Phone:619-417-1168
Mailing Address - Fax:619-532-7617
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:NMCSD
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-7935
Practice Address - Fax:619-532-7617
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105928171000000X, 2083P0901X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program