Provider Demographics
NPI:1447236419
Name:IRIGOYEN, MATILDE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MATILDE
Middle Name:M
Last Name:IRIGOYEN
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 1:5501 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3018
Mailing Address - Country:US
Mailing Address - Phone:215-456-7170
Mailing Address - Fax:215-456-4923
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-7170
Practice Address - Fax:215-456-4923
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430503208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00671458Medicaid
PA101883541Medicaid
NYB16314Medicare UPIN
NY00671458Medicaid
PA101883541Medicaid