Provider Demographics
NPI: | 1538318548 |
---|---|
Name: | SHILLITO, MATTHEW CHARLES (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MATTHEW |
Middle Name: | CHARLES |
Last Name: | SHILLITO |
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: | 6719 ALVARADO RD STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN DIEGO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92120-5256 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 619-229-3932 |
Mailing Address - Fax: | 619-582-2860 |
Practice Address - Street 1: | 6719 ALVARADO RD STE 200 |
Practice Address - Street 2: | |
Practice Address - City: | SAN DIEGO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92120 |
Practice Address - Country: | US |
Practice Address - Phone: | 619-229-3932 |
Practice Address - Fax: | 619-582-2860 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-09-15 |
Last Update Date: | 2020-01-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A109569 | 207XS0106X, 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207XS0106X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | CB29564 | Medicaid | |
CA | 1538318548 | Medicaid | |
CA | 14534033 | Other | CAQH |