Healthcare Provider Details

I. General information

NPI: 1215223409
Provider Name (Legal Business Name): DEEPTI MATHUR M.B;B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2011
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST IRD BUILDING-ROOM 820
LOS ANGELES CA
90033
US

IV. Provider business mailing address

1200 N STATE ST IRD BUILDING-ROOM 820
LOS ANGELES CA
90033-1029
US

V. Phone/Fax

Practice location:
  • Phone: 323-226-3406
  • Fax: 323-226-3440
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0116023276
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA1319591
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: