Basic Information
| Provider Information | |||||||||
| NPI: | 1386006088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELZENBACH | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ST. JOHN'S WELL CHILD | ||||||||
| Address2: | 808 W, 58TH ST | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411411 | ||||||||
| FaxNumber: | 8777207181 | ||||||||
| Practice Location | |||||||||
| Address1: | ST. JOHN'S WELL CHILD | ||||||||
| Address2: | 1910 MAGNOLIA AVE #101 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2137490947 | ||||||||
| FaxNumber: | 2137497354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | A161635 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.