1720088610 NPI number — LONNY MATLICK DO

Table of content: LONNY MATLICK DO (NPI 1720088610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720088610 NPI number — LONNY MATLICK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATLICK
Provider First Name:
LONNY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1720088610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 STONE HARBOR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE MAY COURT HOUSE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08210-2170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-465-4667
Provider Business Mailing Address Fax Number:
609-465-9387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 STONE HARBOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE MAY COURT HOUSE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08210-2170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-465-4667
Provider Business Practice Location Address Fax Number:
609-465-9387
Provider Enumeration Date:
07/21/2005

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: 174400000X , with the licence number:  25MB04094300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2397210 . This is a "AETNA HMO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0373109 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5826793 . This is a "AETNA PPO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P381427 . This is a "OXFORD #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0090415000 . This is a "AMERIHEALTH #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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