Basic Information
| Provider Information | |||||||||
| NPI: | 1255759718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATIALEU | ||||||||
| FirstName: | LEOPOLDINE | ||||||||
| MiddleName: | POUNGUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 855 E MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920203819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8338674642 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 W ARBOR DR # MC8809 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921031911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192338500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | A152369 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.