Healthcare Provider Details

I. General information

NPI: 1013966100
Provider Name (Legal Business Name): JONATHAN MATZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 CAMPBELL BLVD STE 103
WHITE MARSH MD
21162-5503
US

IV. Provider business mailing address

5430 CAMPBELL BLVD STE 103
WHITE MARSH MD
21162-5503
US

V. Phone/Fax

Practice location:
  • Phone: 410-933-9404
  • Fax: 410-933-9405
Mailing address:
  • Phone: 410-933-9404
  • Fax: 410-933-9405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberD0043318
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier123991100
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: