Provider Demographics
NPI:1801160460
Name:CYNTHIA MATHIS MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CYNTHIA MATHIS MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-641-8111
Mailing Address - Street 1:PO BOX 9789
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-2189
Mailing Address - Country:US
Mailing Address - Phone:310-577-8500
Mailing Address - Fax:310-305-7119
Practice Address - Street 1:8930 S SEPULVEDA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3624
Practice Address - Country:US
Practice Address - Phone:310-641-8111
Practice Address - Fax:310-337-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79441208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G37817Medicare UPIN