Healthcare Provider Details

I. General information

NPI: 1730157686
Provider Name (Legal Business Name): ISAAC I MATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HARRISON ST STE 400
JOHNSON CITY NY
13790
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2580
US

V. Phone/Fax

Practice location:
  • Phone: 607-763-8102
  • Fax: 607-770-7375
Mailing address:
  • Phone: 607-729-8156
  • Fax: 607-729-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number111035
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number111035
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: