Healthcare Provider Details

I. General information

NPI: 1841242815
Provider Name (Legal Business Name): ADNAN H MATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/16/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4090 E 14 MILE RD STE 100
WARREN MI
48092-1196
US

IV. Provider business mailing address

4090 E14 MILE RD STE 100
WARREN MI
48092-1196
US

V. Phone/Fax

Practice location:
  • Phone: 586-858-4111
  • Fax: 586-858-4641
Mailing address:
  • Phone: 586-858-4111
  • Fax: 586-858-4641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberAM034389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: