Healthcare Provider Details

I. General information

NPI: 1922265982
Provider Name (Legal Business Name): ADNAN MATTA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
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: 586-838-4441
  • Fax: 586-838-4641
Mailing address:
  • Phone: 586-838-4441
  • Fax: 586-838-4641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301034389
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301034389
License Number StateMI

VIII. Authorized Official

Name: ADNAN HALIM MATTA
Title or Position: PRESIDENT
Credential:
Phone: 586-838-4441