Basic Information
| Provider Information | |||||||||
| NPI: | 1063403590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTS | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 12/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A96301 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PH0002X | A96301 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10329259-1205 | 01 | UT | MEDICAL LICENSE | OTHER | A96301 | 01 | CA | MEDICAL LICENSE | OTHER | 00A963010 | 05 | CA | MEDICAID |