Basic Information
| Provider Information | |||||||||
| NPI: | 1174546295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTHEWS | ||||||||
| FirstName: | H | ||||||||
| MiddleName: | PRESTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATTHEWS | ||||||||
| OtherFirstName: | PRESTON | ||||||||
| OtherMiddleName: | H | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627963 | ||||||||
| FaxNumber: | 5052321627 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 JUAN TABO NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A83286 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00040949 | 05 | NM | MEDICAID | 34K606064 | 01 | NM | MEDICARE PTAN | OTHER |