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General NPI Number Information
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NPI Number | 1457914632
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Entity Type | Individual
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Provider Name | SOFIA MATTA
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Gender | Female
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Dates
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Enumeration Date | 04/15/2019
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Last Update Date | 09/05/2025
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Provider Practice Location Address
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Address Line | 5115 N FRANCISCO AVE
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City | CHICAGO
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State | IL
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Zip | 60625-3611
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Country | US
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Telephone | 847-982-6710
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Fax |
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Provider Business Mailing Address
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Address Line | 2650 RIDGE AVE
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City | EVANSTON
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State | IL
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Zip | 60201-1700
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Country | US
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Telephone | 847-982-6710
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084V0102X
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Taxonomy Name | Vascular Neurology Physician
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License Number | 036176580
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License Number State | IL
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