Provider Demographics
NPI:1013116219
Name:MATT AHMADI, DPM, INC.
Entity type:Organization
Organization Name:MATT AHMADI, DPM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMADI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:949-276-8900
Mailing Address - Street 1:26800 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6384
Mailing Address - Country:US
Mailing Address - Phone:949-276-8900
Mailing Address - Fax:949-276-8901
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 320
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-276-8900
Practice Address - Fax:949-276-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4539213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20884Medicare PIN
CAV00818Medicare UPIN
CA6245910001Medicare NSC