Provider Demographics
NPI:1073773768
Name:CORDOVA, MATTHEW ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:CORDOVA
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 1:68 S SERVICE RD
Mailing Address - Street 2:STE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2354
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:718-250-8848
Practice Address - Fax:718-250-8850
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273111-1207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology