Provider Demographics
NPI:1083602221
Name:MATTERN, CHERYL C (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:C
Last Name:MATTERN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:SAUQUOIT
Mailing Address - State:NY
Mailing Address - Zip Code:13456-2917
Mailing Address - Country:US
Mailing Address - Phone:315-794-3208
Mailing Address - Fax:
Practice Address - Street 1:3007 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:SAUQUOIT
Practice Address - State:NY
Practice Address - Zip Code:13456-2917
Practice Address - Country:US
Practice Address - Phone:315-794-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01214162Medicaid
NYJ400079912Medicare UPIN
NY01214162Medicaid