Provider Demographics
NPI:1629687843
Name:ROSSO, MATTIA (MD)
Entity Type:Individual
Prefix:
First Name:MATTIA
Middle Name:
Last Name:ROSSO
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 1:363 KING ST APT F
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1447
Mailing Address - Country:US
Mailing Address - Phone:843-494-2854
Mailing Address - Fax:
Practice Address - Street 1:96 JONATHAN LUCAS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8900
Practice Address - Country:US
Practice Address - Phone:843-494-2854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL844702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty