Provider Demographics
NPI:1881666956
Name:TADLOCK, MATTHEW DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:TADLOCK
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:619-532-6299
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058634A2083A0100X
CAC547402086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine