Provider Demographics
NPI:1568594828
Name:ETUK, MATTHEW E
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:E
Last Name:ETUK
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MATTHEW
Other - Middle Name:E
Other - Last Name:ETUK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1407 CENTINELA AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-1141
Mailing Address - Country:US
Mailing Address - Phone:310-330-2955
Mailing Address - Fax:310-330-2959
Practice Address - Street 1:1407 CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-1141
Practice Address - Country:US
Practice Address - Phone:310-330-2955
Practice Address - Fax:310-330-2959
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1238310001OtherDURABLE MEDICAL EQUIPMENT