Provider Demographics
NPI:1568474344
Name:MATTINA, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MATTINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 39TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-2456
Mailing Address - Country:US
Mailing Address - Phone:941-747-4664
Mailing Address - Fax:941-747-3067
Practice Address - Street 1:800 39TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-2456
Practice Address - Country:US
Practice Address - Phone:941-747-4664
Practice Address - Fax:941-747-3067
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME15265207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58329Medicare UPIN
FL78016Medicare ID - Type Unspecified