Provider Demographics
NPI:1003974684
Name:MATTA, DIANA (DPM)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MATTA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:DIANA MATTA DPM
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 LENOX AVE
Practice Address - Street 2:DIANA MATTA
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037
Practice Address - Country:US
Practice Address - Phone:212-569-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004506174400000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01128578Medicaid
NYT81561Medicare UPIN
NYP46811Medicare ID - Type Unspecified