Provider Demographics
NPI:1003107699
Name:MATTO, MIKEL (MD)
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:
Last Name:MATTO
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 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:866-617-6855
Mailing Address - Fax:503-346-8015
Practice Address - Street 1:2214 LLOYD CTR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1311
Practice Address - Country:US
Practice Address - Phone:503-494-4222
Practice Address - Fax:503-494-6143
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1224992084P0800X
WA612070812084P0800X
OR2071722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry