Provider Demographics
NPI:1033154463
Name:MATUSOW, GARY (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MATUSOW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 FIRE RD
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-5857
Mailing Address - Country:US
Mailing Address - Phone:609-407-1220
Mailing Address - Fax:321-280-2479
Practice Address - Street 1:3205 FIRE RD
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5857
Practice Address - Country:US
Practice Address - Phone:609-407-1220
Practice Address - Fax:321-280-2479
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05205400174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2345609Medicaid
NJ2345609Medicaid
NJ557019Medicare ID - Type Unspecified