Provider Demographics
NPI:1679644736
Name:MATHIVANNAN, MATTY (MD)
Entity Type:Individual
Prefix:MR
First Name:MATTY
Middle Name:
Last Name:MATHIVANNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AMBAL
Other - Middle Name:
Other - Last Name:MATHIVANNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:2141 K ST NW
Practice Address - Street 2:SUITE 606
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-1810
Practice Address - Country:US
Practice Address - Phone:202-293-8680
Practice Address - Fax:202-293-8694
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD31203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037070700Medicaid
DC037070700Medicaid
H00393Medicare UPIN