Provider Demographics
NPI:1255409884
Name:MATTY, TERESA MARIA (MD)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MARIA
Last Name:MATTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 5TH ST SE
Mailing Address - Street 2:STE. B
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-4259
Mailing Address - Country:US
Mailing Address - Phone:330-745-4188
Mailing Address - Fax:
Practice Address - Street 1:101 5TH ST SE
Practice Address - Street 2:STE. B
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-4259
Practice Address - Country:US
Practice Address - Phone:330-745-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH037175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH300497760OtherTAXPAYER IDENTIFICATION
OH0346290Medicaid
OHA75335Medicare UPIN
OHMA0412372Medicare ID - Type Unspecified