Provider Demographics
NPI:1336534338
Name:KORNSWIET, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KORNSWIET
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 1:23521 PASEO DE VALENCIA STE 200
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3101
Mailing Address - Country:US
Mailing Address - Phone:949-951-5437
Mailing Address - Fax:
Practice Address - Street 1:23521 PASEO DE VALENCIA STE 200
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3101
Practice Address - Country:US
Practice Address - Phone:949-951-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A171972080S0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Single Specialty