Healthcare Provider Details

I. General information

NPI: 1811998578
Provider Name (Legal Business Name): JACQUELINE R MATAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 BOB O LINK DR SUITE 120
LEXINGTON KY
40504-3759
US

IV. Provider business mailing address

870 CORPORATE DR STE. 400
LEXINGTON KY
40503-5416
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-3737
  • Fax: 859-277-3765
Mailing address:
  • Phone: 859-277-9436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number24630
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: