Provider Demographics
NPI:1114943842
Name:MATTIMORE, CRYSTAL WILLIAMS (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:WILLIAMS
Last Name:MATTIMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:VERONICA
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2417 TOPANGA SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:TOPANGA
Mailing Address - State:CA
Mailing Address - Zip Code:90290-4054
Mailing Address - Country:US
Mailing Address - Phone:310-455-1536
Mailing Address - Fax:
Practice Address - Street 1:2417 TOPANGA SKYLINE DR
Practice Address - Street 2:
Practice Address - City:TOPANGA
Practice Address - State:CA
Practice Address - Zip Code:90290-4054
Practice Address - Country:US
Practice Address - Phone:310-455-1536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40029207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH19679Medicare UPIN