Healthcare Provider Details

I. General information

NPI: 1912401142
Provider Name (Legal Business Name): MATTHEW VINCENT TANZI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD STONY BROOK MEDICINE, DEPT OF EM, HSC LEVEL 4, RM 050
STONY BROOK NY
11794
US

IV. Provider business mailing address

101 NICOLLS RD STONY BROOK MEDICINE, DEPT OF EM, HSC LEVEL 4, RM 050
STONY BROOK NY
11794
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2478
  • Fax: 631-444-3919
Mailing address:
  • Phone: 631-444-2478
  • Fax: 631-444-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number309203
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: