Provider Demographics
NPI:1457552457
Name:LETIZIA, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LETIZIA
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 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:225 WILLIAMSON ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-3625
Practice Address - Country:US
Practice Address - Phone:908-994-5454
Practice Address - Fax:919-425-0478
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08192400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0139882Medicaid
NJ115215WJ8Medicare PIN