Provider Demographics
NPI:1073612057
Name:MYLENE V MATTI, M.D., INC.
Entity Type:Organization
Organization Name:MYLENE V MATTI, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYLENE
Authorized Official - Middle Name:V
Authorized Official - Last Name:MATTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-759-9090
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91102-0456
Mailing Address - Country:US
Mailing Address - Phone:510-759-9090
Mailing Address - Fax:
Practice Address - Street 1:240 E DEL MAR BLVD UNIT 104
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-5513
Practice Address - Country:US
Practice Address - Phone:510-759-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53842207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A538420Medicaid
CA00A538420Medicaid
CAZZZ28723ZMedicare PIN