Provider Demographics
NPI:1699789461
Name:MATKIWSKY, WALTER (DO)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:MATKIWSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HOLLYWOOD AVE
Practice Address - Street 2:HILLSIDE FAMILY PRACTICE
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205
Practice Address - Country:US
Practice Address - Phone:908-353-7949
Practice Address - Fax:908-353-8374
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02410900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2195704Medicaid
456699Medicare ID - Type Unspecified
NJ2195704Medicaid