Provider Demographics
NPI:1912940214
Name:MATALA-SULLIVAN, MARIA ELENA (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:ELENA
Last Name:MATALA-SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 CAMP RD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075
Mailing Address - Country:US
Mailing Address - Phone:716-646-1084
Mailing Address - Fax:716-646-0786
Practice Address - Street 1:4855 CAMP RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075
Practice Address - Country:US
Practice Address - Phone:716-646-1084
Practice Address - Fax:716-646-0786
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY404544OtherWELLCARE
NY01874813Medicaid
CC8391Medicare ID - Type Unspecified
DD8671Medicare PIN
NYP00337698Medicare PIN
NY01874813Medicaid
NY404544OtherWELLCARE
NYCC8391Medicare PIN