Provider Demographics
NPI:1588694764
Name:DI MATTEO, LUCA (DPM)
Entity type:Individual
Prefix:DR
First Name:LUCA
Middle Name:
Last Name:DI MATTEO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 HOPMEADOW STREET
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2415
Mailing Address - Country:US
Mailing Address - Phone:860-651-8557
Mailing Address - Fax:860-651-9558
Practice Address - Street 1:538 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-2415
Practice Address - Country:US
Practice Address - Phone:860-651-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000596213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004123139Medicaid
CT030000596CT01OtherANTHEM BLUE SHIELD
CT030000596CT01OtherANTHEM BLUE SHIELD
CT004123139Medicaid