Provider Demographics
NPI:1437770724
Name:MATTA, MARINA (MD)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:MATTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MANCHESTER CT APT A
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-3227
Mailing Address - Country:US
Mailing Address - Phone:917-697-5854
Mailing Address - Fax:
Practice Address - Street 1:222 STATION PLZ N STE 509
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3893
Practice Address - Country:US
Practice Address - Phone:516-663-8794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY325197208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program