Provider Demographics
NPI:1841868437
Name:DAVIS, MATTHEW B
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:DAVIS
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 1:24 SAND BAR DR
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-3548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 SAND BAR DR
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08721-3548
Practice Address - Country:US
Practice Address - Phone:859-379-9365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ87-1155694Medicaid