1568659563 NPI number — DANIEL MATEMOTJA, MD INC

Table of content: (NPI 1568659563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568659563 NPI number — DANIEL MATEMOTJA, MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANIEL MATEMOTJA, MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MAY FAMILY MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568659563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 E ROSECRANS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST RANCHO DOMINGUEZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90221-2143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-635-5223
Provider Business Mailing Address Fax Number:
310-635-8246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 E ROSECRANS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST RANCHO DOMINGUEZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90221-2143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-635-5223
Provider Business Practice Location Address Fax Number:
310-635-8246
Provider Enumeration Date:
10/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATEMOTJA
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-635-5223

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A35512 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A35512 . This is a "MEDICAL LICENSE DIRECTOR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0100760 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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