MEDICARE: ELLI JACOB MATATOV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1720697048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLI JACOB MATATOV

Provider Business Mailing Address
First Line	:	714 E 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2202
Country	:	US
Telephone Number	:	347-462-7521
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 E 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2202
Country	:	US
Telephone Number	:	347-462-7521
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2020
Last Update Date	:	07/23/2020

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