Provider Demographics
NPI:1558900712
Name:COUSE, MATTHEW RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:COUSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DISPENSERY RD
Mailing Address - Street 2:
Mailing Address - City:POINT MUGU NAWC
Mailing Address - State:CA
Mailing Address - Zip Code:93042-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 DISPENSARY ROAD
Practice Address - Street 2:
Practice Address - City:POINT MUGU NAWC
Practice Address - State:CA
Practice Address - Zip Code:93042-2111
Practice Address - Country:US
Practice Address - Phone:805-989-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-04
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206795171000000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program