Provider Demographics
NPI:1013909068
Name:MATTERA, ANTHONY M (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:M
Last Name:MATTERA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 ROYAL DUBLIN LN
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1273
Mailing Address - Country:US
Mailing Address - Phone:708-705-0123
Mailing Address - Fax:219-227-9077
Practice Address - Street 1:732 ROYAL DUBLIN LN
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1273
Practice Address - Country:US
Practice Address - Phone:219-864-2235
Practice Address - Fax:219-365-1398
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036039136207QG0300X
IN02000262207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036039136Medicaid
IN140220WWWMedicare PIN
IL036039136Medicaid
ILL91466Medicare ID - Type Unspecified