Basic Information
| Provider Information | |||||||||
| NPI: | 1528030996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTAI | ||||||||
| FirstName: | S. ANJANI | ||||||||
| MiddleName: | DEVI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 UCLA MEDICAL PLZ STE 490 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900247003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102068000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A69997 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 210549 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528030996 | 05 | CA | MEDICAID |