Healthcare Provider Details

I. General information

NPI: 1790722353
Provider Name (Legal Business Name): TEJ K. MATTOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDRENS HOSPITAL OF MICHIGAN 3901 BEAUBIEN BLVD - NEPHROLOGY
DETROIT MI
48201
US

IV. Provider business mailing address

4201 ST. ANTOINE - UHC 5D MAILBOX 226 UNIVERSITY PEDIATRICIANS
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5604
  • Fax: 313-966-0039
Mailing address:
  • Phone: 313-745-4405
  • Fax: 313-966-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number068731
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: