Provider Demographics
NPI:1760774327
Name:MATTA, DANIELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:
Last Name:MATTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:
Practice Address - Street 1:14551 HOPE CENTER LOOP STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4705
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:239-936-3099
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS142902085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging