Healthcare Provider Details

I. General information

NPI: 1801605035
Provider Name (Legal Business Name): TAMAR-MATTIS, D.O., A PROFESSIONAL ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 GRAVENSTEIN HWY S STE 120
SEBASTOPOL CA
95472-4863
US

IV. Provider business mailing address

1020 GRAVENSTEIN HWY S STE 120
SEBASTOPOL CA
95472-4863
US

V. Phone/Fax

Practice location:
  • Phone: 707-861-0807
  • Fax:
Mailing address:
  • Phone: 707-861-0807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANNE TAMAR-MATTIS
Title or Position: CHIEF ADMINSITRATIVE OFFICER
Credential:
Phone: 707-861-0807