1033276282 NPI number — ITZHAK MATUSIAK PH.D

Table of content: ITZHAK MATUSIAK PH.D (NPI 1033276282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033276282 NPI number — ITZHAK MATUSIAK PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATUSIAK
Provider First Name:
ITZHAK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033276282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7161 N PORT WASHINGTON RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53217-3877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-352-7682
Provider Business Mailing Address Fax Number:
414-352-7625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7161 N PORT WASHINGTON RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53217-3877
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-352-7682
Provider Business Practice Location Address Fax Number:
414-352-7625
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  0650 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39007000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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