Provider Demographics
NPI:1447590245
Name:LANDON, MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:LANDON
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 1:8573 TOMMY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-2009
Mailing Address - Country:US
Mailing Address - Phone:619-865-2654
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS RD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:760-830-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY3039332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty