Provider Demographics
NPI:1922027390
Name:DIMATTIA, SAMARA M (MS,PT)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:M
Last Name:DIMATTIA
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-2429
Mailing Address - Country:US
Mailing Address - Phone:203-569-1274
Mailing Address - Fax:203-674-8990
Practice Address - Street 1:1275 SUMMER ST
Practice Address - Street 2:SUITE 307
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5359
Practice Address - Country:US
Practice Address - Phone:203-569-1274
Practice Address - Fax:203-569-1274
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000497Medicare ID - Type Unspecified