Provider Demographics
NPI:1396797809
Name:ENNA, MATTHEW JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:ENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9033 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1837
Mailing Address - Country:US
Mailing Address - Phone:310-858-3880
Mailing Address - Fax:888-589-6241
Practice Address - Street 1:9033 WILSHIRE BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1837
Practice Address - Country:US
Practice Address - Phone:310-858-3880
Practice Address - Fax:888-589-6241
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100628207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45-2457553OtherCORPORATE TAX ID#
CAAO296XMedicare PIN
CA45-2457553OtherCORPORATE TAX ID#