Provider Demographics
NPI:1427315126
Name:MATILSKY, NOAH B (MD)
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:B
Last Name:MATILSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W WARREN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4038
Mailing Address - Country:US
Mailing Address - Phone:407-262-2220
Mailing Address - Fax:407-834-5011
Practice Address - Street 1:455 W WARREN AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4038
Practice Address - Country:US
Practice Address - Phone:407-262-2220
Practice Address - Fax:407-834-5011
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012621842084P0800X, 2084P0804X
FLME1239382084P0800X, 2084P0804X
FLME1645162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119433400Medicaid