Provider Demographics
NPI:1902283922
Name:MATATOVA, ROZA
Entity Type:Individual
Prefix:
First Name:ROZA
Middle Name:
Last Name:MATATOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-2247
Mailing Address - Country:US
Mailing Address - Phone:347-891-5226
Mailing Address - Fax:
Practice Address - Street 1:1171 OCEAN PKWY APT 3A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-4024
Practice Address - Country:US
Practice Address - Phone:347-891-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY692844374T00000X
NYF352257-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel