Healthcare Provider Details

I. General information

NPI: 1124940184
Provider Name (Legal Business Name): BETH MARIE MATVYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 OLD COUNTRY RD STE C103N
WESTBURY NY
11590-5156
US

IV. Provider business mailing address

119 MAPLE PL
PORT JEFFERSON NY
11777-1632
US

V. Phone/Fax

Practice location:
  • Phone: 631-398-2784
  • Fax:
Mailing address:
  • Phone: 631-398-2784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10865505
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: