Healthcare Provider Details

I. General information

NPI: 1942706056
Provider Name (Legal Business Name): MARK ELLIOTT MATUSAK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21311 MADRONA AVE STE 100A
TORRANCE CA
90503-5970
US

IV. Provider business mailing address

21311 MADRONA AVE STE 100A
TORRANCE CA
90503-5970
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-4400
  • Fax:
Mailing address:
  • Phone: 310-792-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A18824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: