Provider Demographics
NPI:1356480503
Name:MATERNA, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:MATERNA
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 1:87 LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2304
Mailing Address - Country:US
Mailing Address - Phone:973-744-4265
Mailing Address - Fax:
Practice Address - Street 1:20 FERRY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1420
Practice Address - Country:US
Practice Address - Phone:973-589-0104
Practice Address - Fax:973-589-5084
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03400000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1465201Medicaid
NJ061280694OtherTAX ID
NJC55275Medicare UPIN
NJ452045Medicare ID - Type UnspecifiedPROVIDER NUMBER