Provider Demographics
NPI:1295999399
Name:MATATOV, LEV Y (CFO,BOCO,COTA)
Entity type:Individual
Prefix:
First Name:LEV
Middle Name:Y
Last Name:MATATOV
Suffix:
Gender:M
Credentials:CFO,BOCO,COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7721 166TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1232
Mailing Address - Country:US
Mailing Address - Phone:646-267-2409
Mailing Address - Fax:516-213-2732
Practice Address - Street 1:7721 166TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1232
Practice Address - Country:US
Practice Address - Phone:646-267-2409
Practice Address - Fax:516-213-2732
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY222Z00000X
NY004659224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No174400000XOther Service ProvidersSpecialist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02864OtherAMERICAN BOARD CERTIFIED FITTER- ORTHOTICS