Provider Demographics
NPI:1306833660
Name:MATIENZO, RICARDO (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:MATIENZO
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 1:450 7TH ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2057
Mailing Address - Country:US
Mailing Address - Phone:201-659-0711
Mailing Address - Fax:201-659-4117
Practice Address - Street 1:450 7TH ST
Practice Address - Street 2:SUITE 9
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-2057
Practice Address - Country:US
Practice Address - Phone:201-659-0711
Practice Address - Fax:201-659-4117
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA075238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9033009Medicaid
NJ9033009Medicaid
NJ066930Medicare ID - Type Unspecified