Healthcare Provider Details

I. General information

NPI: 1902283922
Provider Name (Legal Business Name): ROZA MATATOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 OCEAN PKWY APT 3A
BROOKLYN NY
11230-4024
US

IV. Provider business mailing address

800 E 8TH ST
BROOKLYN NY
11230-2247
US

V. Phone/Fax

Practice location:
  • Phone: 347-891-5226
  • Fax:
Mailing address:
  • Phone: 347-891-5226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number692844
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF352257-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: