Basic Information
| Provider Information | |||||||||
| NPI: | 1629032271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANZLER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | HARRISON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104982374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 KEARNEY STREET | ||||||||
| Address2: | DERMATOLOGY DEPARTMENT | ||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945382299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104901222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | G57056 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X | G57056 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | G57056 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 00G570560 | 05 | CA | MEDICAID |