Basic Information
| Provider Information | |||||||||
| NPI: | 1730184425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTERN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | QA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6350 CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572135700 | ||||||||
| FaxNumber: | 7572135701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1051 LOFTIS BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236063069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578739400 | ||||||||
| FaxNumber: | 7578739420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 0102024256 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 110054750 | 01 | VA | RAILROAD MEDICARE | OTHER | 005808855 | 05 | VA | MEDICAID | 55097 | 01 | VA | OPTIMA | OTHER |