Provider Demographics
NPI:1770580920
Name:MATTSON, EDWIN W (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:W
Last Name:MATTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 N. MAGNOLIA AVE.
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1236 N. MAGNOLIA AVE.
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2607
Practice Address - Country:US
Practice Address - Phone:714-995-1000
Practice Address - Fax:714-828-7926
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G807280OtherMEDI CAL
CAG64685Medicare UPIN