Provider Demographics
NPI:1689347940
Name:CRISOSTOMO, MATTHEW VELARDE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:VELARDE
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 GREENTREE DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-1028
Mailing Address - Country:US
Mailing Address - Phone:707-567-9589
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3239
Practice Address - Country:US
Practice Address - Phone:800-607-6377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95051922163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse