MEDICARE: MATAYBO MEDICAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1730347923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATAYBO MEDICAL PLLC

Provider Business Mailing Address
First Line	:	1236 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2093
Country	:	US
Telephone Number	:	718-230-4200
Fax Number	:	718-230-4277

Provider Business Practice Location Address
First Line	:	1236 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2093
Country	:	US
Telephone Number	:	718-230-4200
Fax Number	:	718-230-4277

Authorized Official
Title or Position	:	ADMINISTRATIVE PARTNER
Name	:	DR. TERRY BLACKETT-BONNETT
Credential	:	M.D.
Telephone Number	:	718-230-4200

Provider Enumeration Date	:	05/26/2008
Last Update Date	:	05/26/2008

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