Provider Demographics
NPI:1821002759
Name:MATEMOTJA, DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:MATEMOTJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 EAST ROSECRANS AVENUE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221
Mailing Address - Country:US
Mailing Address - Phone:310-635-5223
Mailing Address - Fax:310-635-2846
Practice Address - Street 1:711 EAST ROSECRANS AVENUE
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221
Practice Address - Country:US
Practice Address - Phone:310-635-5223
Practice Address - Fax:310-635-2846
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A355121Medicaid
CA954825811OtherTAX ID
CAGR0100760OtherGROUP MEDICAID
CAGR0100760OtherGROUP MEDICAID
CAA35512Medicare ID - Type UnspecifiedMEDICARE
CAW11731Medicare PIN