Provider Demographics
NPI:1881632081
Name:HOM, MATTHEW HERBERT (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:HERBERT
Last Name:HOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54118
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0118
Mailing Address - Country:US
Mailing Address - Phone:619-686-3935
Mailing Address - Fax:619-686-3874
Practice Address - Street 1:4077 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-686-3935
Practice Address - Fax:619-686-3874
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68160207RG0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A681601Medicaid
CAH16757Medicare UPIN
CAA68160AMedicare ID - Type Unspecified
CA00A681601Medicaid