Provider Demographics
NPI:1013101914
Name:MATTHEWS, MARK A
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MATTHEWS
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 1:6310 7TH AVE
Mailing Address - Street 2:6313 7TH AVENUE
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-4275
Mailing Address - Country:US
Mailing Address - Phone:323-778-0718
Mailing Address - Fax:
Practice Address - Street 1:6310 7TH AVE
Practice Address - Street 2:6313 7TH AVENUE
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-4275
Practice Address - Country:US
Practice Address - Phone:323-778-0718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALVN 180296164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse