Provider Demographics
NPI:1659548204
Name:MATHEW, MAYA MARY (MD)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:MARY
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 MASSELIN AVE
Mailing Address - Street 2:#423
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5763
Mailing Address - Country:US
Mailing Address - Phone:323-356-5816
Mailing Address - Fax:504-988-3971
Practice Address - Street 1:1225 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2395
Practice Address - Country:US
Practice Address - Phone:213-977-2121
Practice Address - Fax:213-202-7028
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113265207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine