Provider Demographics
NPI:1174921951
Name:MATIAS, JACQUELINE DIANE
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DIANE
Last Name:MATIAS
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 1:15 SOUNDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-1101
Mailing Address - Country:US
Mailing Address - Phone:631-849-1664
Mailing Address - Fax:
Practice Address - Street 1:538 BROADHOLLOW RD STE 202
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3668
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist