Provider Demographics
NPI:1770511891
Name:MATZA, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MATZA
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 1:1389 W MAIN ST
Mailing Address - Street 2:SUITE 123
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-755-5555
Mailing Address - Fax:
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:SUITE 123
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-755-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020509207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001205095Medicaid
CTB38938Medicare UPIN
CT20000453Medicare PIN