Provider Demographics
NPI:1538318548
Name:SHILLITO, MATTHEW CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:CHARLES
Last Name:SHILLITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6719 ALVARADO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5256
Mailing Address - Country:US
Mailing Address - Phone:619-229-3932
Mailing Address - Fax:619-582-2860
Practice Address - Street 1:6719 ALVARADO RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120
Practice Address - Country:US
Practice Address - Phone:619-229-3932
Practice Address - Fax:619-582-2860
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109569207XS0106X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB29564Medicaid
CA1538318548Medicaid
CA14534033OtherCAQH