Provider Demographics
NPI:1235282864
Name:FOBI, MATHIAS AL (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:MATHIAS
Middle Name:AL
Last Name:FOBI
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5695 BAHIA MAR CIR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1604
Mailing Address - Country:US
Mailing Address - Phone:310-617-4334
Mailing Address - Fax:
Practice Address - Street 1:21520 PIONEER BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2603
Practice Address - Country:US
Practice Address - Phone:562-402-9779
Practice Address - Fax:562-402-9449
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30361174400000X
GA80447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG30361AMedicare UPIN
CAA89495Medicare ID - Type Unspecified