Provider Demographics
NPI:1518334515
Name:MATTA, STEPHANY KHALIL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANY
Middle Name:KHALIL
Last Name:MATTA
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 1:75 KNEELAND ST LBBY 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1906
Mailing Address - Country:US
Mailing Address - Phone:617-636-8920
Mailing Address - Fax:
Practice Address - Street 1:905 UNION ST STE 11
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3039
Practice Address - Country:US
Practice Address - Phone:207-973-8423
Practice Address - Fax:207-973-7424
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264574207RE0101X
390200000X
MEMD24165207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program