Provider Demographics
NPI:1659313989
Name:PINE-MATTAS, DENISE (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:PINE-MATTAS
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:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2505
Mailing Address - Country:US
Mailing Address - Phone:812-238-7783
Mailing Address - Fax:812-238-4506
Practice Address - Street 1:410 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441-1010
Practice Address - Country:US
Practice Address - Phone:217-826-2361
Practice Address - Fax:217-826-2366
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114511207Q00000X
IN01060692A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00459732OtherRR MEDICARE
IN200876850Medicaid
INP00459735OtherRR MEDICARE
IL036114511Medicaid
IN130910LLMedicare PIN
IL036114511Medicaid
INP00459735Medicare PIN
ILI74210Medicare UPIN
IN200876850Medicaid
IN941090V7Medicare PIN
ILP00459732OtherRR MEDICARE
ILP00459732Medicare PIN