Provider Demographics
NPI:1518911049
Name:MATIN, TANJILA (DPM)
Entity Type:Individual
Prefix:DR
First Name:TANJILA
Middle Name:
Last Name:MATIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 ALEXANDRA CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT BETHEL
Mailing Address - State:PA
Mailing Address - Zip Code:18343-5781
Mailing Address - Country:US
Mailing Address - Phone:570-431-0788
Mailing Address - Fax:570-431-0706
Practice Address - Street 1:109 SEVEN BRIDGES RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301
Practice Address - Country:US
Practice Address - Phone:570-431-0788
Practice Address - Fax:570-431-0708
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00282300213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019459670001Medicaid
PA1019459670001Medicaid