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General NPI Number Information
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NPI Number | 1356480503
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Entity Type | Individual
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Provider Name | THOMAS W MATERNA M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/05/2007
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Last Update Date | 01/13/2014
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Provider Practice Location Address
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Address Line | 20 FERRY ST
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City | NEWARK
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State | NJ
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Zip | 07105-1420
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Country | US
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Telephone | 973-589-0104
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Fax | 973-589-5084
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Provider Business Mailing Address
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Address Line | 87 LORRAINE AVE
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City | UPPER MONTCLAIR
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State | NJ
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Zip | 07043-2304
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Country | US
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Telephone | 973-744-4265
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 25MA03400000
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License Number State | NJ
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