MEDICARE: MARINA MATATOVA D.O.

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	390200000X	Student in an Organized Health Care Education/Training Program	259160	NY
2	207N00000X	Dermatology Physician	259160	NY

General Provider Information

NPI Number	:	1881977304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA MATATOVA D.O.

Provider Business Mailing Address
First Line	:	4037 74TH ST
Second Line	:
City	:	ELMHURST
State	:	NY
Zip	:	11373-5603
Country	:	US
Telephone Number	:	718-651-7000
Fax Number	:	718-606-8966

Provider Business Practice Location Address
First Line	:	4037 74TH ST
Second Line	:
City	:	ELMHURST
State	:	NY
Zip	:	11373-5603
Country	:	US
Telephone Number	:	718-651-7000
Fax Number	:	718-606-8966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	11/10/2020

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