Healthcare Provider Details

I. General information

NPI: 1497048722
Provider Name (Legal Business Name): MATTHEW NICHOLAS SUBERLAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

64 MIDLAND PL APT 2611
TUCKAHOE NY
10707-4251
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5230
  • Fax:
Mailing address:
  • Phone: 925-216-6418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number289990
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: