Healthcare Provider Details

I. General information

NPI: 1831347426
Provider Name (Legal Business Name): DEBORA MATOSSIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR DHMC - DEPT OF PEDIATRIC NEPHROLOGY
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR DHMC - DEPT OF PEDIATRIC NEPHROLOGY
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-653-9884
  • Fax: 603-650-0907
Mailing address:
  • Phone: 603-653-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number15670
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: