Provider Demographics
NPI:1609891571
Name:MATAR, SALIM A (MD)
Entity Type:Individual
Prefix:MR
First Name:SALIM
Middle Name:A
Last Name:MATAR
Suffix:
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 1:640 BELLE TERRE RD
Mailing Address - Street 2:BUILDING C
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1936
Mailing Address - Country:US
Mailing Address - Phone:631-928-7750
Mailing Address - Fax:631-928-7867
Practice Address - Street 1:640 BELLE TERRE RD
Practice Address - Street 2:BUILDING C
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1936
Practice Address - Country:US
Practice Address - Phone:631-928-7750
Practice Address - Fax:631-928-7867
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191264174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33H371Medicare ID - Type Unspecified