Provider Demographics
NPI:1245326131
Name:MATJUCHA, JOHN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:MATJUCHA
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:PO BO 13700 0135
Mailing Address - Street 2:NEWARD BETH ISRAEL EMERGENCY ROOM DEPARTMENT
Mailing Address - City:PHILADELPHI
Mailing Address - State:PA
Mailing Address - Zip Code:19191-0135
Mailing Address - Country:US
Mailing Address - Phone:610-668-6491
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:201 LYONS AVENUE
Practice Address - Street 2:NEWARD BETH ISRAEL MEDICAL CENTER
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2094
Practice Address - Country:US
Practice Address - Phone:973-926-7000
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05951100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G61957Medicare UPIN
NJ003830Medicare ID - Type Unspecified