Basic Information
| Provider Information | |||||||||
| NPI: | 1891805826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5333 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905105333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103292469 | ||||||||
| FaxNumber: | 3103290176 | ||||||||
| Practice Location | |||||||||
| Address1: | 239 S LA CIENEGA BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902113328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106599566 | ||||||||
| FaxNumber: | 3103290176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | G79441 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 246014400 | 01 | CA | OWCP-FEDERAL EMPLOYEES CO | OTHER | 00G794410 | 05 | CA | MEDICAID |