Provider Demographics
NPI:1851364939
Name:SLATALLA, MATT DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:DANIEL
Last Name:SLATALLA
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:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:CLN 309 ANESTHESIA ASSOCIATES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-665-1630
Practice Address - Fax:617-665-1091
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209222207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA209222OtherTUFTS HEALTH PLAN
MAJ24069OtherBCBS MA
MA0196037Medicaid
MA0196037Medicaid
MAA33100Medicare ID - Type Unspecified