Provider Demographics
NPI:1982767067
Name:MATOS, MARSHALL IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:IRA
Last Name:MATOS
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 1:140 LOCKWOOD AVENUE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-4915
Mailing Address - Country:US
Mailing Address - Phone:914-576-7171
Mailing Address - Fax:914-840-1112
Practice Address - Street 1:140 LOCKWOOD AVENUE
Practice Address - Street 2:SUITE 310
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4915
Practice Address - Country:US
Practice Address - Phone:914-576-7171
Practice Address - Fax:914-576-4770
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135068207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
2C4798OtherHEALTHNET
0795550OtherCIGNA
0079828OtherGHI
93A791OtherBLUE CROSS
WS965OtherOXFORD
0079828OtherGHI
93A791Medicare ID - Type Unspecified