Provider Demographics
NPI:1073130506
Name:MATTU, NAMITA
Entity Type:Individual
Prefix:
First Name:NAMITA
Middle Name:
Last Name:MATTU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MEDFORD ST APT 216
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 MEDFORD ST APT 216
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-1989
Practice Address - Country:US
Practice Address - Phone:510-289-0826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1873122084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program