Basic Information
| Provider Information | |||||||||
| NPI: | 1396797809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENNA | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9033 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902111837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108583880 | ||||||||
| FaxNumber: | 8885896241 | ||||||||
| Practice Location | |||||||||
| Address1: | 9033 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902111837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108583880 | ||||||||
| FaxNumber: | 8885896241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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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 | 207X00000X | A100628 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 45-2457553 | 01 | CA | CORPORATE TAX ID# | OTHER |