Provider Demographics
NPI:1114065406
Name:IMANGULI, MATIN MIKAYIL (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:MATIN
Middle Name:MIKAYIL
Last Name:IMANGULI
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 ROUTE 66 FL 3
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2645
Mailing Address - Country:US
Mailing Address - Phone:732-807-0877
Mailing Address - Fax:201-751-1680
Practice Address - Street 1:102 JAMES ST STE 302
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3970
Practice Address - Country:US
Practice Address - Phone:732-635-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411071122300000X
TXQ0461207Y00000X
AL36041207Y00000X
NJ25MA10294300207Y00000X, 207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No122300000XDental ProvidersDentist
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA542034392OtherTAX IDENTIFICATION
VA113660124OtherTAX IDENTIFICATION
VA841629676OtherTAX IDENTIFICATION