Provider Demographics
NPI:1285960914
Name:FALLON, MATTHEW ROBERT
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:FALLON
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 1:2100 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3577
Mailing Address - Country:US
Mailing Address - Phone:631-580-2526
Mailing Address - Fax:
Practice Address - Street 1:2100 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3577
Practice Address - Country:US
Practice Address - Phone:631-580-2526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031965-1283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital