Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 02000262 | IN |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 036039136 | IL |
NPI | 1013909068 |
---|---|
Provider Name | Anthony M Mattera |
First Address | Dyer, IN 46311-1273 |
Second Address | Dyer, IN 46311-1273 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2005 |
Last Update Date | 20/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036039136 | (05) | IL |
D11429 | (02) |