Provider Demographics
NPI:1316945702
Name:MATOSSIAN, HARRY BERJ (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:BERJ
Last Name:MATOSSIAN
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 1:234 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4560
Mailing Address - Country:US
Mailing Address - Phone:707-462-0681
Mailing Address - Fax:707-462-4647
Practice Address - Street 1:234 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4560
Practice Address - Country:US
Practice Address - Phone:707-462-0681
Practice Address - Fax:707-462-4647
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2024-08-26
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
CAG62323207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ56549ZOtherBLUE SHIELD OF CALIFORNIA
CA00G623230Medicaid
CAA53686Medicare UPIN
CA00G623230Medicaid