Provider Demographics
NPI:1720088610
Name:MATLICK, LONNY (DO)
Entity Type:Individual
Prefix:
First Name:LONNY
Middle Name:
Last Name:MATLICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 STONE HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE MAY COURT HOUSE
Mailing Address - State:NJ
Mailing Address - Zip Code:08210-2170
Mailing Address - Country:US
Mailing Address - Phone:609-465-4667
Mailing Address - Fax:609-465-9387
Practice Address - Street 1:307 STONE HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:CAPE MAY COURT HOUSE
Practice Address - State:NJ
Practice Address - Zip Code:08210-2170
Practice Address - Country:US
Practice Address - Phone:609-465-4667
Practice Address - Fax:609-465-9387
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04094300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2397210OtherAETNA HMO
NJ0373109Medicaid
NJ5826793OtherAETNA PPO
NJP381427OtherOXFORD #
NJ0090415000OtherAMERIHEALTH #
NJ5826793OtherAETNA PPO
NJ182585PJTMedicare PIN
NJE06170Medicare UPIN