Provider Demographics
NPI:1619061678
Name:MERLISS, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MERLISS
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 1:1133 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2601
Mailing Address - Country:US
Mailing Address - Phone:530-934-1831
Mailing Address - Fax:530-934-1818
Practice Address - Street 1:1133 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-2601
Practice Address - Country:US
Practice Address - Phone:530-934-1831
Practice Address - Fax:530-934-1818
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG043655207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49418Medicare UPIN