Provider Demographics
NPI:1952379356
Name:MATUSEVICH, BORIS (MD)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:MATUSEVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 BETH LN
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1544
Mailing Address - Country:US
Mailing Address - Phone:516-374-6326
Mailing Address - Fax:
Practice Address - Street 1:1175 MONTAUK HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4939
Practice Address - Country:US
Practice Address - Phone:631-321-0570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217094-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
9K2761Medicare ID - Type Unspecified