Provider Demographics
NPI:1770286718
Name:MATTAR, SHADI DANIEL (DPM)
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:DANIEL
Last Name:MATTAR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15820 36TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-4749
Mailing Address - Country:US
Mailing Address - Phone:425-877-4677
Mailing Address - Fax:
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-8401
Practice Address - Fax:503-413-7361
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program