Healthcare Provider Details

I. General information

NPI: 1629520325
Provider Name (Legal Business Name): RYAN M MATTOON AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ROUTE 70 STE 14
LAKEWOOD NJ
08701-5961
US

IV. Provider business mailing address

2253 CRESTWOOD PL
FORKED RIVER NJ
08731-3128
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-5991
  • Fax:
Mailing address:
  • Phone: 201-421-5384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number41YA00095400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: