Provider Demographics
NPI:1942706056
Name:MATUSAK, MARK ELLIOTT
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ELLIOTT
Last Name:MATUSAK
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 1:1100 DELAPLAINE CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1840
Mailing Address - Country:US
Mailing Address - Phone:608-263-4550
Mailing Address - Fax:608-263-5813
Practice Address - Street 1:6801 PARK TER STE 400
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-9212
Practice Address - Country:US
Practice Address - Phone:310-665-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A18824207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program