Provider Demographics
NPI:1457597114
Name:MATELJAN, THOMAS JAMES
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:MATELJAN
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 1:6936 WILLOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-1464
Mailing Address - Country:US
Mailing Address - Phone:262-664-5727
Mailing Address - Fax:262-681-2173
Practice Address - Street 1:6936 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-1464
Practice Address - Country:US
Practice Address - Phone:262-664-5727
Practice Address - Fax:262-681-2173
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor