Provider Demographics
NPI:1871599480
Name:MATTANA, GUY W (DPM)
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:W
Last Name:MATTANA
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 1:150 N RIVER RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1272
Mailing Address - Country:US
Mailing Address - Phone:847-487-2827
Mailing Address - Fax:847-487-2860
Practice Address - Street 1:150 N RIVER RD
Practice Address - Street 2:STE 220
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1272
Practice Address - Country:US
Practice Address - Phone:847-487-2827
Practice Address - Fax:847-487-2860
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003633213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL584730Medicare PIN
IL212569Medicare PIN
IL364290Medicare PIN
ILT37699Medicare UPIN
IL754811Medicare PIN
IL583450Medicare PIN