Provider Demographics
NPI:1548622301
Name:MATAR, NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:MATAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:GREAT RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11739-0626
Mailing Address - Country:US
Mailing Address - Phone:631-892-2745
Mailing Address - Fax:631-201-3179
Practice Address - Street 1:1 BLACHLEY RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-0002
Practice Address - Country:US
Practice Address - Phone:203-705-0948
Practice Address - Fax:203-705-0938
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11138600207LP2900X
NY302738207LP2900X
CT79958207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine