Provider Demographics
NPI:1972995413
Name:MCCORMACK, MATTHEW THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESCANSO DR
Mailing Address - Street 2:#152
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-1890
Mailing Address - Country:US
Mailing Address - Phone:805-345-0895
Mailing Address - Fax:
Practice Address - Street 1:130 DESCANSO DR
Practice Address - Street 2:#152
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-1890
Practice Address - Country:US
Practice Address - Phone:805-345-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33171111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor