Provider Demographics
NPI:1730425844
Name:MATTHEW LUBLIN MD INC
Entity type:Organization
Organization Name:MATTHEW LUBLIN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-739-1127
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 1170W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-828-2212
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 1170W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-828-2212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82116208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB781AOtherMEDICARE PTAN