Provider Demographics
NPI:1508914235
Name:MICHAEL A MATTES, DPM A PROF CORP
Entity Type:Organization
Organization Name:MICHAEL A MATTES, DPM A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER PRACTITONER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MATTES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-789-3668
Mailing Address - Street 1:13351D RIVERSIDE DR # 604
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2508
Mailing Address - Country:US
Mailing Address - Phone:818-789-3668
Mailing Address - Fax:818-906-0777
Practice Address - Street 1:13351D RIVERSIDE DR # 604
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2508
Practice Address - Country:US
Practice Address - Phone:818-789-3668
Practice Address - Fax:818-906-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3418213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE3418Medicaid
CAT19325Medicare UPIN
CAE3418Medicaid