Healthcare Provider Details

I. General information

NPI: 1902541402
Provider Name (Legal Business Name): CHRISTOPHER MATTIELLO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 04/29/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S 11TH ST
PHILADELPHIA PA
19107-4949
US

IV. Provider business mailing address

590 LOWER LANDING RD APT 24F
BLACKWOOD NJ
08012-4226
US

V. Phone/Fax

Practice location:
  • Phone: 215-503-3876
  • Fax: 215-955-2519
Mailing address:
  • Phone: 908-601-6986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: