Provider Demographics
NPI:1730400359
Name:BAUER, MATTHEW THOMAS (IDC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BAUER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS BOXER
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-7112
Mailing Address - Country:US
Mailing Address - Phone:619-556-4122
Mailing Address - Fax:
Practice Address - Street 1:USS BOXER
Practice Address - Street 2:LHD 8
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96667
Practice Address - Country:US
Practice Address - Phone:619-556-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman