Provider Demographics
NPI:1952526345
Name:MATTERA, TINA M (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:MATTERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 LINCOLN AVE
Mailing Address - Street 2:UNIT W
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3104
Mailing Address - Country:US
Mailing Address - Phone:630-541-8930
Mailing Address - Fax:630-541-8940
Practice Address - Street 1:5950 LINCOLN AVE
Practice Address - Street 2:UNIT W
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3104
Practice Address - Country:US
Practice Address - Phone:630-541-8930
Practice Address - Fax:630-541-8940
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360995112084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBCBSOther022-27624