Provider Demographics
NPI:1053452417
Name:MATIN, FAZLE (MD)
Entity Type:Individual
Prefix:
First Name:FAZLE
Middle Name:
Last Name:MATIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 WEST LEE STREET
Mailing Address - Street 2:
Mailing Address - City:TUSKEGEE
Mailing Address - State:AL
Mailing Address - Zip Code:36083
Mailing Address - Country:US
Mailing Address - Phone:334-727-7050
Mailing Address - Fax:334-727-6284
Practice Address - Street 1:203 WEST LEE STREET
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083
Practice Address - Country:US
Practice Address - Phone:334-727-7050
Practice Address - Fax:334-727-6284
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00022310208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51005213OtherBC
AL631000021Medicaid
AL631000021Medicaid
AL05213Medicare ID - Type Unspecified