Healthcare Provider Details

I. General information

NPI: 1699401521
Provider Name (Legal Business Name): LAVI MATTINGLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 2ND AVE
LONG BRANCH NJ
07740-6303
US

IV. Provider business mailing address

1 CHELSEA AVE APT 208
LONG BRANCH NJ
07740-8125
US

V. Phone/Fax

Practice location:
  • Phone: 732-923-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: