Provider Demographics
NPI:1851491849
Name:EDWIN MATIAS, M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:EDWIN MATIAS, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:MAUN
Authorized Official - Last Name:MATIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-795-6596
Mailing Address - Street 1:225 S LAKE AVE
Mailing Address - Street 2:535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3005
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:2131 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1901
Practice Address - Country:US
Practice Address - Phone:213-484-7953
Practice Address - Fax:213-413-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46461207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A464160Medicaid
CA2411535OtherMEDICAL PIN
CA00A464160OtherBLUE SHIELD
CAW18933OtherGRUOP MCR
CA00A464160OtherBLUE SHIELD
CA00A464160Medicaid
CAWA46416GMedicare PIN
CAA46416DMedicare PIN