Provider Demographics
NPI:1881795490
Name:MATELA, MICHAEL B (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:MATELA
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 1:16 STERLING DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9133
Mailing Address - Country:US
Mailing Address - Phone:681-342-3453
Mailing Address - Fax:
Practice Address - Street 1:912 SOMERSET BLVD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-3954
Practice Address - Country:US
Practice Address - Phone:304-725-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60794489207Q00000X
WV25248207Q00000X
WI42848-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G55223Medicare UPIN