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1881786119

NPI Code Detail

MEDICARE: DR. NINA LOUISE MATTARELLA MD

MEDICARE: DR. NINA LOUISE MATTARELLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	4301054688	MI
2	208M00000X	Hospitalist Physician	4301054688	MI
3	208000000X	Pediatrics Physician	MD185106	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3503334051	OTHER	MI	BCBS INDIVIDUAL PIN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881786119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NINA LOUISE MATTARELLA MD

Provider Business Mailing Address
First Line	:	PO BOX 1194
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97339-1194
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2870 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367-5127
Country	:	US
Telephone Number	:	541-994-9191
Fax Number	:	541-994-9034

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	11/04/2020

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Directions to “ DR. NINA LOUISE MATTARELLA MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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