Provider Demographics
NPI:1669469003
Name:MATUKAS, ANTHONY GEDIMINAS (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:GEDIMINAS
Last Name:MATUKAS
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 1:2505 SAMARITAN DR
Mailing Address - Street 2:601
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4006
Mailing Address - Country:US
Mailing Address - Phone:408-358-1717
Mailing Address - Fax:408-358-1718
Practice Address - Street 1:2505 SAMARITAN DR
Practice Address - Street 2:601
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4006
Practice Address - Country:US
Practice Address - Phone:408-358-1717
Practice Address - Fax:408-358-1718
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11143207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A38242Medicare UPIN
CA00G111430Medicare ID - Type Unspecified