Healthcare Provider Details

I. General information

NPI: 1245615350
Provider Name (Legal Business Name): RYAN MATTIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 S FAIR OAKS AVE
PASADENA CA
91105
US

IV. Provider business mailing address

1017 S FAIR OAKS AVE
PASADENA CA
91105-2621
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-6200
  • Fax: 626-403-2580
Mailing address:
  • Phone: 626-403-6200
  • Fax: 626-403-2580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA131777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: