Healthcare Provider Details

I. General information

NPI: 1447336771
Provider Name (Legal Business Name): NIDAL MATALKAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HAMBURG TPKE SUITE 107
WAYNE NJ
07470-2154
US

IV. Provider business mailing address

PO BOX 2336
WAYNE NJ
07470
US

V. Phone/Fax

Practice location:
  • Phone: 973-595-7456
  • Fax: 973-904-9119
Mailing address:
  • Phone: 973-595-7456
  • Fax: 973-904-9119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMA061937
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMA061937
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: