Healthcare Provider Details

I. General information

NPI: 1790280311
Provider Name (Legal Business Name): MATTHEW MACDONALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

100 EAST 77TH STREET 6 BLACK HALL
NEW YORK NY
10075-1850
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number313483
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA12352200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: