Healthcare Provider Details

I. General information

NPI: 1962674960
Provider Name (Legal Business Name): NILESH MATHURIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ SUITE 365C
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-2235
  • Fax: 310-825-2092
Mailing address:
  • Phone: 310-206-2235
  • Fax: 310-825-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL9801
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC53713
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC53713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: