Provider Demographics
NPI:1225086598
Name:SHAWL, MATTHEW WAYNE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:SHAWL
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 1:853 BROADWAY
Mailing Address - Street 2:SUITE 903
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:212-787-6900
Mailing Address - Fax:917-421-9786
Practice Address - Street 1:853 BROADWAY
Practice Address - Street 2:SUITE 903
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-787-6900
Practice Address - Fax:917-421-9786
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208640207Y00000X
708640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02168963Medicaid
NY02168963Medicaid
NY6M4621Medicare PIN