Provider Demographics
NPI:1568402881
Name:MATARESE, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MATARESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19328 US ROUTE 11
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5337
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:19328 US ROUTE 11
Practice Address - Street 2:SUITE B
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5337
Practice Address - Country:US
Practice Address - Phone:315-782-0136
Practice Address - Fax:315-782-7212
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY112674207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00273698Medicaid
B13227Medicare UPIN
NY51763BMedicare PIN