Provider Demographics
NPI:1578622916
Name:MATTHEWS, EDWARD JOHN JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHN
Last Name:MATTHEWS
Suffix:JR
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 1:7379 AMBOY ROAD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307
Mailing Address - Country:US
Mailing Address - Phone:718-984-2005
Mailing Address - Fax:718-984-2005
Practice Address - Street 1:7379 AMBOY ROAD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10307
Practice Address - Country:US
Practice Address - Phone:718-984-2005
Practice Address - Fax:718-984-2005
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147351207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A63715Medicare UPIN
67A641Medicare ID - Type Unspecified