Healthcare Provider Details

I. General information

NPI: 1205451655
Provider Name (Legal Business Name): MATTIAS DINO D'ANNA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E 39TH ST S
INDEPENDENCE MO
64057-2301
US

IV. Provider business mailing address

19600 E 39TH ST S
INDEPENDENCE MO
64057-2301
US

V. Phone/Fax

Practice location:
  • Phone: 913-222-9779
  • Fax:
Mailing address:
  • Phone: 913-222-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2023010864
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: