Healthcare Provider Details

I. General information

NPI: 1265167506
Provider Name (Legal Business Name): SARA SALEM MATTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

IV. Provider business mailing address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

V. Phone/Fax

Practice location:
  • Phone: 619-280-4213
  • Fax:
Mailing address:
  • Phone: 619-280-4213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberPA62020
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberPA62020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: