Provider Demographics
NPI:1699423459
Name:MICHIENZI, MATTHEW RYAN (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:MICHIENZI
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:BROOKE ARMY MEDICAL CENTER PEDIATRICS
Mailing Address - Street 2:3551 ROGER BROOKE DR.
Mailing Address - City:JBSA-FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:210-916-9928
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER PEDIATRICS
Practice Address - Street 2:3551 ROGER BROOKE DR.
Practice Address - City:JBSA-FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-916-9928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider