Provider Demographics
NPI:1952339590
Name:VIVIENNE IRENE MATALON MD PC
Entity Type:Organization
Organization Name:VIVIENNE IRENE MATALON MD PC
Other - Org Name:TLC HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIENNE
Authorized Official - Middle Name:I
Authorized Official - Last Name:MATALON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-985-0590
Mailing Address - Street 1:230 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-985-0590
Mailing Address - Fax:856-985-2866
Practice Address - Street 1:230 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-985-0590
Practice Address - Fax:856-985-2866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1923005Medicaid
NJ092320Medicare PIN
E40217Medicare UPIN