Provider Demographics
NPI:1205378940
Name:ISLAM, MATTHEW LEE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:ISLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 3RD AVE N APT 11
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-3286
Mailing Address - Country:US
Mailing Address - Phone:561-312-9012
Mailing Address - Fax:
Practice Address - Street 1:1733 3RD AVE N APT 11
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-3286
Practice Address - Country:US
Practice Address - Phone:561-312-9012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital