Provider Demographics
NPI:1720284334
Name:GRACE ZLAKET MATTA MD LLC
Entity Type:Organization
Organization Name:GRACE ZLAKET MATTA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR - PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZLAKET-MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-219-5597
Mailing Address - Street 1:9336 E, RAINTREE DR.
Mailing Address - Street 2:STE 150
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-7314
Mailing Address - Country:US
Mailing Address - Phone:480-219-5597
Mailing Address - Fax:480-219-5547
Practice Address - Street 1:9336 E, RAINTREE DR.
Practice Address - Street 2:STE 150
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-7314
Practice Address - Country:US
Practice Address - Phone:480-219-5597
Practice Address - Fax:480-219-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23480174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ326480Medicaid
AZ326480Medicaid
AZG17440Medicare UPIN