Matthew Civilette
Individual provider Active NPI General Practice Physician · Coronado, CA
NPI 1053069724 · NPPES record last updated Mar 14, 2024
Key facts
- NPI
- 1053069724
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Physician 208D00000X
- License
- 0101279134 (VA)
- Practice address
- 601 McCain Blvd.
Coronado, CA 92118 - Phone
- (716) 785-8351
- NPI assigned
- Mar 12, 2022
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0101279134 | VA | MD | General Practice Physician |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| General Practice Physician | 208D00000X | 0101279134 | VA | Yes |
Addresses
Primary practice location
601 McCain Blvd.
Coronado, CA 92118
Mailing address
601 McCain Blvd
Coronado, CA 92118
Other providers in Coronado, CA
- Alexis Guadalupe Chavez
- Byeng Yuen Choi
- Chris S. Pallia, MD, Apc
- Chung Dental Corporation
- City of Coronado
- Laura Mead Clapper
- Coastal Concierge Physicians
- Jill Collins
- Kristine Collins
- Community Birth Group
All providers in Coronado, CA · General Practice Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 14, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.