Provider Demographics
NPI:1568783009
Name:MATTA, STEPHEN (DO, MBA)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:MATTA
Suffix:
Gender:M
Credentials:DO, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 LYCEUM AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3418
Mailing Address - Country:US
Mailing Address - Phone:267-314-7555
Mailing Address - Fax:267-314-7555
Practice Address - Street 1:441 LYCEUM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3418
Practice Address - Country:US
Practice Address - Phone:267-314-7555
Practice Address - Fax:267-314-7555
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-014889207Q00000X
PAOS014889207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACD4829OtherTPI GROUP RAILROAD MEDICARE
PA597586OtherTPI GROUP MEDICARE
NJ102643666Medicaid
PA1007278000OtherTPI MEDICAID GROUP
PACD4829OtherTPI GROUP RAILROAD MEDICARE