Healthcare Provider Details

I. General information

NPI: 1730347923
Provider Name (Legal Business Name): MATAYBO MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2008
Last Update Date: 05/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1236 FULTON ST
BROOKLYN NY
11216-2093
US

IV. Provider business mailing address

1236 FULTON ST
BROOKLYN NY
11216-2093
US

V. Phone/Fax

Practice location:
  • Phone: 718-230-4200
  • Fax: 718-230-4277
Mailing address:
  • Phone: 718-230-4200
  • Fax: 718-230-4277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TERRY BLACKETT-BONNETT
Title or Position: ADMINISTRATIVE PARTNER
Credential: M.D.
Phone: 718-230-4200