Provider Demographics
NPI:1467647768
Name:MATTIA, CAMILLE R (MD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:R
Last Name:MATTIA
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:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:
Practice Address - Street 1:3890 TAMPA RD
Practice Address - Street 2:SUITE 305
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3677
Practice Address - Country:US
Practice Address - Phone:727-781-3160
Practice Address - Fax:727-533-5900
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001371400Medicaid
FLP00775166OtherRAILROAD MEDICARE PROVIDER NUMBER
FLCH116ZMedicare PIN