Provider Demographics
NPI:1790980316
Name:ULRICKSON, MATTHEW L (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:ULRICKSON
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 1:2940 E BANNER GATEWAY DR
Mailing Address - Street 2:#450
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2168
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:
Practice Address - Street 1:2940 E BANNER GATEWAY DR
Practice Address - Street 2:#450
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47540207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0297081OtherLABOR AND INDUSTRY
WA0297081OtherLABOR AND INDUSTRY