Provider Demographics
NPI:1225140205
Name:MATTES, CAROL ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ELIZABETH
Last Name:MATTES
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 1:21785 FILIGREE CT
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6213
Mailing Address - Country:US
Mailing Address - Phone:703-554-1100
Mailing Address - Fax:703-430-6985
Practice Address - Street 1:21785 FILIGREE CT
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6213
Practice Address - Country:US
Practice Address - Phone:703-554-1100
Practice Address - Fax:703-430-6985
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101272084Medicaid
H87109Medicare UPIN