Provider Demographics
NPI:1821502683
Name:REAGAN, MATTHEW LAURANCE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LAURANCE
Last Name:REAGAN
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 1:10139 GLENNON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2914
Mailing Address - Country:US
Mailing Address - Phone:619-274-0158
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-473-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman