Provider Demographics
NPI:1619984812
Name:DE MATTOS, ANGELO MARIO (MD)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:MARIO
Last Name:DE MATTOS
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-3442
Mailing Address - Fax:503-494-5330
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-3442
Practice Address - Fax:503-494-5330
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD192424207RN0300X
AL26093207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009981565Medicaid
MS04808231OtherMISSISSIPPI MEDCAID
AL051524242OtherBLUE CROSS
AL009981555Medicaid
AL051524243OtherBLUE CROSS
ALP00159465OtherRAILROAD MEDICARE
AL051524243OtherBLUE CROSS