Provider Demographics
NPI:1184069825
Name:MATHEW, ANNA JOHN (MD)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:JOHN
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:P. O BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-2582
Mailing Address - Fax:
Practice Address - Street 1:1450 SAN PABLO STREET
Practice Address - Street 2:2ND FLOOR LAB
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-4500
Practice Address - Country:US
Practice Address - Phone:323-442-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116340207ZP0102X, 207ZP0102X
MS21473207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08678877Medicaid
CAA116340OtherCA MED LICENCE
MS295588YR8UMedicare PIN