Provider Demographics
NPI:1003841800
Name:CONOLLY, MATTHEW ELLIS (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ELLIS
Last Name:CONOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-206-6232
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#214,365,530,420,120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34351207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A343510Medicaid
CAWA34351BMedicare PIN
CAA27458Medicare UPIN