Basic Information
| Provider Information | |||||||||
| NPI: | 1235301714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | MANAGED CARE DEPT | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 963 BUTTE ST | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960010828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302455900 | ||||||||
| FaxNumber: | 5302455909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2008 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0001X | ME102606 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | A111934 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000738600 | 05 | FL | MEDICAID | 3285093 | 01 | CA | CIGNA | OTHER | P00857460 | 01 | CA | RAILROAD MEDICARE | OTHER | 9973229 | 01 | FL | AETNA | OTHER | 3285093 | 01 | FL | CIGNA | OTHER | 1235301714 | 01 | CA | CALIFORNIA CHILDRENS SERVICES PROGRAM | OTHER | P304208 | 01 | FL | FREEDOM HEALTH | OTHER | P202295 | 01 | FL | FREEDOM OPTIMUN | OTHER |