Provider Demographics
NPI:1316193410
Name:WOLDETSADIK, MATTHIAS TADESSE
Entity Type:Individual
Prefix:
First Name:MATTHIAS
Middle Name:TADESSE
Last Name:WOLDETSADIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 S LA BREA AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-5251
Mailing Address - Country:US
Mailing Address - Phone:310-927-2464
Mailing Address - Fax:
Practice Address - Street 1:3515 S LA BREA AVE APT 107
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-5251
Practice Address - Country:US
Practice Address - Phone:310-927-2464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program