Provider Demographics
NPI:1730157686
Name:MATTA, ISAAC I (MD)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:I
Last Name:MATTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:STE 400
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:607-763-8102
Practice Address - Fax:607-770-7375
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111035207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00365233Medicaid
B34602Medicare UPIN
NYJ400059239Medicare PIN
NY00365233Medicaid