Provider Demographics
NPI:1841401031
Name:MATTAR, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MATTAR
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 1:3800 RESERVOIR RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2113
Mailing Address - Country:US
Mailing Address - Phone:024-448-5412
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007
Practice Address - Country:US
Practice Address - Phone:024-448-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247425207RG0100X
DCMD036652207RG0100X
CAA95008207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12120494OtherCAQH