Healthcare Provider Details

I. General information

NPI: 1013273390
Provider Name (Legal Business Name): NICHOLAS PHILIP MATARAZZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 KINGS HWY N
WESTPORT CT
06880-2440
US

IV. Provider business mailing address

156 KINGS HWY N
WESTPORT CT
06880-2440
US

V. Phone/Fax

Practice location:
  • Phone: 203-221-7337
  • Fax: 203-291-0830
Mailing address:
  • Phone: 203-221-7337
  • Fax: 203-291-0830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number054195
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: