Provider Demographics
NPI:1629238449
Name:MATULLO, KRISTOFER STEFFEN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:STEFFEN
Last Name:MATULLO
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 1:801 OSTRUM ST
Mailing Address - Street 2:PRISCILLA PAYNE HURD PAVILION 2
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:610-954-1735
Mailing Address - Fax:610-954-2429
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:PRISCILLA PAYNE HURD PAVILION 2
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1000
Practice Address - Country:US
Practice Address - Phone:610-954-1735
Practice Address - Fax:610-954-2429
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51196207XS0106X
PAMD427003207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN200002734Medicare PIN