Provider Demographics
NPI:1881300770
Name:MATERNA, MITCHELL REED (DC)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:REED
Last Name:MATERNA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 BERRYESSA RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2900
Mailing Address - Country:US
Mailing Address - Phone:408-258-0812
Mailing Address - Fax:408-258-4550
Practice Address - Street 1:2680 BERRYESSA RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-2900
Practice Address - Country:US
Practice Address - Phone:408-258-0812
Practice Address - Fax:408-258-4550
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013870111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor