Basic Information
Provider Information
NPI: 1003142985
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROOSEVELT
FirstName: MATTHEW
MiddleName: JAMES
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4746 ZION AVE.
Address2: DEPARTMENT OF HOSPITAL MEDICINE
City: SAN DIEGO
State: CA
PostalCode: 921200000
CountryCode: US
TelephoneNumber: 6199525091
FaxNumber:  
Practice Location
Address1: 4647 ZION AVE
Address2: DEPARTMENT OF HOSPITAL MEDICINE
City: SAN DIEGO
State: CA
PostalCode: 921202507
CountryCode: US
TelephoneNumber: 6199525091
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/27/2009
LastUpdateDate: 08/15/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XA114981CAY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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