Basic Information
| Provider Information | |||||||||
| NPI: | 1487984027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EARLY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | NAVAL MEDICAL CENTER 34800 BOB WILSON DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921340001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195326827 | ||||||||
| FaxNumber: | 6195327508 | ||||||||
| Practice Location | |||||||||
| Address1: | FLEET SURGICAL TEAM THREE 3895 CUMMINGS RD SUITE 4 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921362428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195564352 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2010 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | Y | Other Service Providers | Military Health Care Provider |
ID Information
| ID | Type | State | Issuer | Description | VAD0000 | 05 | CA | MEDICAID |