Provider Demographics
NPI:1669731394
Name:MATTA, ELIAS N (MD)
Entity type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:N
Last Name:MATTA
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 1:501 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4634
Mailing Address - Country:US
Mailing Address - Phone:727-898-7451
Mailing Address - Fax:
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-898-7451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122561208000000X, 2080P0204X
NJ25MA09039000208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics