Provider Demographics
NPI:1902954613
Name:MATTES, MICHAEL ALAN (DPM, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:MATTES
Suffix:
Gender:M
Credentials:DPM, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13351D RIVERSIDE DR # 604
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2508
Mailing Address - Country:US
Mailing Address - Phone:818-789-3668
Mailing Address - Fax:818-906-0777
Practice Address - Street 1:13351D RIVERSIDE DR # 604
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2508
Practice Address - Country:US
Practice Address - Phone:818-789-3668
Practice Address - Fax:818-906-0777
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35498183500000X
CAE3418213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT19325Medicare UPIN
CAAS998Medicare PIN