Healthcare Provider Details

I. General information

NPI: 1780685479
Provider Name (Legal Business Name): MARTIN MATHEW ANDERSON M.D. MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8215 VAN NUYS BLVD
PANORAMA CITY CA
91402-4839
US

IV. Provider business mailing address

1172 N MACLAY AVE
SAN FERNANDO CA
91340-1328
US

V. Phone/Fax

Practice location:
  • Phone: 818-988-6335
  • Fax: 818-988-2140
Mailing address:
  • Phone: 818-898-1388
  • Fax: 818-365-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG48857
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: