Basic Information
| Provider Information | |||||||||
| NPI: | 1538152004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTU | ||||||||
| FirstName: | SEJAL | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12332 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816460 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 BRANDERMILL BLVD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | GAMBRILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210541690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104517214 | ||||||||
| FaxNumber: | 4104517218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0052139 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32483 | 01 | KAISER | OTHER | 74841805 | 01 | BCBS | OTHER | 282075 | 01 | MAMSI | OTHER | 5504586 | 01 | AETNA PPO | OTHER | 2167135 | 01 | AETNA HMO | OTHER | 0001 | 01 | BCBS | OTHER | 201233200 | 01 | FEDERAL WORKMANS COMP | OTHER | 942161102 | 05 | MD | MEDICAID |