Provider Demographics
NPI:1861617417
Name:MAYNARD, MATTHEW TAM (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TAM
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20044 CEDAR RD N STE A
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5900
Mailing Address - Country:US
Mailing Address - Phone:209-536-3750
Mailing Address - Fax:209-532-9811
Practice Address - Street 1:20044 CEDAR RD N STE A
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5900
Practice Address - Country:US
Practice Address - Phone:209-536-3750
Practice Address - Fax:209-532-9811
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2009-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015815207V00000X
NMT-521207V00000X
CA20A10864207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology