Provider Demographics
NPI:1104093301
Name:MATATOV, TIM (MD)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:MATATOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2801 E CAMELBACK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4363
Mailing Address - Country:US
Mailing Address - Phone:480-576-4310
Mailing Address - Fax:480-576-4311
Practice Address - Street 1:2801 E CAMELBACK RD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4363
Practice Address - Country:US
Practice Address - Phone:480-576-4310
Practice Address - Fax:480-576-4311
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ522172086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA06171Medicaid