Provider Demographics
NPI:1619645397
Name:THOMAS, MATTHEW BLAKE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BLAKE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1340
Mailing Address - Country:US
Mailing Address - Phone:518-481-8160
Mailing Address - Fax:
Practice Address - Street 1:15 4TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1340
Practice Address - Country:US
Practice Address - Phone:518-481-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1987Medicaid