=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134501885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMIE L MATTEO DPM, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2015
-----------------------------------------------------
Last Update Date | 02/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 628 NILES CORTLAND ROAD SE SUITE 103
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44484-2473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-372-2218
-----------------------------------------------------
Fax | 234-600-5237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 628 NILES CORTLAND ROAD SE SUITE 103
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44484-2473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-372-2218
-----------------------------------------------------
Fax | 234-600-5237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMIE L MATTEO
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 330-372-2218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 003719
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------