Provider Demographics
NPI:1528209103
Name:NUCKOLS, MATTHEW CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:CHARLES
Last Name:NUCKOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3626 RUFFIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1810
Mailing Address - Country:US
Mailing Address - Phone:858-565-9666
Mailing Address - Fax:858-565-9441
Practice Address - Street 1:3626 RUFFIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1810
Practice Address - Country:US
Practice Address - Phone:858-565-9666
Practice Address - Fax:858-565-9441
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA108006207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB236280Medicare PIN