Basic Information
| Provider Information | |||||||||
| NPI: | 1184673568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLUKE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | MARC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6428 | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955026428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074455431 | ||||||||
| FaxNumber: | 7074453710 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 BUHNE ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074427814 | ||||||||
| FaxNumber: | 7074453710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/16/2012 | ||||||||
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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 | 2085R0202X | G85606 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300107988 | 01 | RR MEDICARE | OTHER | 00G856060 | 05 | CA | MEDICAID |