Basic Information
| Provider Information | |||||||||
| NPI: | 1508247800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDOCH | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | GME OFFICE WESTERLY SUITE C | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | GME OFFICE WESTERLY SUITE C | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584085 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 56618 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 437751 | 05 | AZ | MEDICAID |