Provider Demographics
NPI:1528022712
Name:PERSONIUS, MATTHEW LINCOLN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LINCOLN
Last Name:PERSONIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 FAIRVIEW LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4809
Mailing Address - Country:US
Mailing Address - Phone:209-532-4287
Mailing Address - Fax:209-532-4289
Practice Address - Street 1:183 FAIRVIEW LN
Practice Address - Street 2:SUITE A
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4809
Practice Address - Country:US
Practice Address - Phone:209-532-4287
Practice Address - Fax:209-532-4289
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00019043OtherRAILROAD MEDICARE
CA00A625120Medicaid
CAG60980Medicare UPIN
CA00A625120Medicaid