Basic Information
| Provider Information | |||||||||
| NPI: | 1083672786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTKE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | FEAZEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1745 PHOENIX BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303495591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709949326 | ||||||||
| FaxNumber: | 7709944747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 MILSTEAD AVE NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709949326 | ||||||||
| FaxNumber: | 7709944747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35.123208 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 057540 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.