=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518621291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TASNIM MATIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2021
-----------------------------------------------------
Last Update Date | 10/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BROOKDALE PLZ
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11212-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-240-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3053 69TH ST FL 2
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-384-0578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | P112843
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------