Healthcare Provider Details

I. General information

NPI: 1407778533
Provider Name (Legal Business Name): KANWARJIT MATTU APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 LORAIN AVE
CLEVELAND OH
44102-4897
US

IV. Provider business mailing address

16444 SELBY CIR
STRONGSVILLE OH
44136-6482
US

V. Phone/Fax

Practice location:
  • Phone: 216-658-1615
  • Fax: 440-345-5151
Mailing address:
  • Phone: 330-888-3808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN.469814
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: