Provider Demographics
NPI:1003814229
Name:HARRY B. MATOSSIAN
Entity Type:Organization
Organization Name:HARRY B. MATOSSIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:BERJ
Authorized Official - Last Name:MATOSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-462-3190
Mailing Address - Street 1:234 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4560
Mailing Address - Country:US
Mailing Address - Phone:707-462-3190
Mailing Address - Fax:707-462-4647
Practice Address - Street 1:234 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4560
Practice Address - Country:US
Practice Address - Phone:707-462-3190
Practice Address - Fax:707-462-4647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1100514261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAS1639OtherBLUE CROSS OF CALIFORNIA
CA05-C0001639OtherMEDICARE LICENSE NUMBER
CAP00117803OtherRAILROAD MEDICARE
CAZZZH23012OtherBLUE SHIELD OF CALIFORNIA
CAX34617Medicare UPIN
CAZZZ27461ZMedicare ID - Type Unspecified