Provider Demographics
NPI:1629006978
Name:MATTIKOW, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:MATTIKOW
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 1:2282 HAMBURG TPKE
Mailing Address - Street 2:SUITE E
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-6291
Mailing Address - Country:US
Mailing Address - Phone:973-696-7300
Mailing Address - Fax:973-835-0520
Practice Address - Street 1:2282 HAMBURG TPKE
Practice Address - Street 2:SUITE E
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-6291
Practice Address - Country:US
Practice Address - Phone:973-696-7300
Practice Address - Fax:973-835-0520
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02206300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ471804OtherMEDICARE PROVIDER ID