Provider Demographics
NPI:1679652135
Name:MATTA, SHAKTI K (MBBS, DCH, MD, FAAP)
Entity Type:Individual
Prefix:DR
First Name:SHAKTI
Middle Name:K
Last Name:MATTA
Suffix:
Gender:M
Credentials:MBBS, DCH, MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 W RIO GRANDE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7684
Mailing Address - Country:US
Mailing Address - Phone:509-572-2201
Mailing Address - Fax:509-783-8844
Practice Address - Street 1:6802 W RIO GRANDE AVE STE 1
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7684
Practice Address - Country:US
Practice Address - Phone:509-572-2201
Practice Address - Fax:509-783-8844
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035969208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0124991OtherWA STATE DL&I #
WA8227530Medicaid
WAG87174Medicare UPIN
WAP00113644Medicare ID - Type UnspecifiedRR MEDICARE #
WA0124991OtherWA STATE DL&I #