Provider Demographics
NPI:1710943816
Name:PAUL, MATTHEW KENICHI (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KENICHI
Last Name:PAUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2662 EDITH AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-3043
Mailing Address - Country:US
Mailing Address - Phone:530-395-0340
Mailing Address - Fax:530-255-6107
Practice Address - Street 1:2662 EDITH AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3043
Practice Address - Country:US
Practice Address - Phone:530-395-0340
Practice Address - Fax:530-255-6107
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94289207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710943816Medicaid