Provider Demographics
NPI:1538870670
Name:MATOVU, MARK TIMOTHY
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:TIMOTHY
Last Name:MATOVU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 DIXIE CT APT 201
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-5432
Mailing Address - Country:US
Mailing Address - Phone:815-212-5867
Mailing Address - Fax:
Practice Address - Street 1:1845 GRANDSTAND PL
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-6603
Practice Address - Country:US
Practice Address - Phone:815-219-6584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator