=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073612057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYLENE V MATTI, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 05/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 E DEL MAR BLVD UNIT 104
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-759-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 456
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91102-0456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-759-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MYLENE V MATTI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 510-759-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A53842
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------