Basic Information
| Provider Information | |||||||||
| NPI: | 1467409334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTAR | ||||||||
| FirstName: | AHMED | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3508 STIRLING ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763101723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406898234 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1301 3RD STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763012245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9407675145 | ||||||||
| FaxNumber: | 9407673027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 10/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M2705 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 24248 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01042539A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35-066806 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 180623405 | 05 | TX | MEDICAID |