Provider Demographics
NPI:1952643793
Name:SANIDAD, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SANIDAD
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 1:7917 WILLFIELD CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-3181
Mailing Address - Country:US
Mailing Address - Phone:703-599-1186
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:GRAY-BIGELOW 444
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA270190207L00000X
390200000X
VA0101269068207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program