Provider Demographics
NPI:1922044015
Name:DEMATTEO, MARK P (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:DEMATTEO
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 1:111 GROSSMAN DR
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4997
Mailing Address - Country:US
Mailing Address - Phone:781-849-1000
Mailing Address - Fax:
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150129207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA766710OtherTUFTS
MA3158250Medicaid
MA930100100OtherRAILROAD MEDICARE
MAJ17389OtherBLUE CROSS BLUE SHIELD
MA766710OtherTUFTS
MAA21649Medicare PIN
MAG33953Medicare UPIN