Basic Information
| Provider Information | |||||||||
| NPI: | 1861617417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | TAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20044 CEDAR RD N STE A | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363750 | ||||||||
| FaxNumber: | 2095329811 | ||||||||
| Practice Location | |||||||||
| Address1: | 20044 CEDAR RD N STE A | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363750 | ||||||||
| FaxNumber: | 2095329811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 10/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101015815 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | T-521 | NM | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 20A10864 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.