Healthcare Provider Details

I. General information

NPI: 1508914235
Provider Name (Legal Business Name): MICHAEL A MATTES, DPM A PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13351D RIVERSIDE DR # 604
SHERMAN OAKS CA
91423-2508
US

IV. Provider business mailing address

13351D RIVERSIDE DR # 604
SHERMAN OAKS CA
91423-2508
US

V. Phone/Fax

Practice location:
  • Phone: 818-789-3668
  • Fax: 818-906-0777
Mailing address:
  • Phone: 818-789-3668
  • Fax: 818-906-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3418
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL ALAN MATTES
Title or Position: PRESIDENT OWNER PRACTITONER
Credential: DPM
Phone: 818-789-3668