Provider Demographics
NPI:1679216121
Name:ALLEN, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17234 VALLEY BLVD.
Mailing Address - Street 2:BLDG. A
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17234 VALLEY BLVD.
Practice Address - Street 2:BLDG. A
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:402-450-9429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1907322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program