Provider Demographics
NPI:1740280650
Name:MUELLENHOFF, MATTHEW WERNER (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WERNER
Last Name:MUELLENHOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 GLASSON WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5706
Mailing Address - Country:US
Mailing Address - Phone:530-272-2303
Mailing Address - Fax:530-272-9648
Practice Address - Street 1:126 GLASSON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5706
Practice Address - Country:US
Practice Address - Phone:530-272-2303
Practice Address - Fax:530-272-9648
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7904207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI14855Medicare UPIN
CAZZZ30150ZMedicare ID - Type Unspecified