Basic Information
| Provider Information | |||||||||
| NPI: | 1962431247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATIAS | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | MAUN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S 1ST ST | ||||||||
| Address2: | 1000 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915021938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188456206 | ||||||||
| FaxNumber: | 8188459774 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134847953 | ||||||||
| FaxNumber: | 2134136338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A46461 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | A46416D | 01 | CA | MEDICARE LEGACY NUMBER | OTHER | 00A464160 | 01 | CA | BLUE SHIELD | OTHER | 00A464160 | 05 | CA | MEDICAID |