Provider Demographics
NPI:1811998578
Name:MATAR, JACQUELINE R (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:R
Last Name:MATAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 CORPORATE DR
Mailing Address - Street 2:STE. 400
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-5416
Mailing Address - Country:US
Mailing Address - Phone:859-277-9436
Mailing Address - Fax:
Practice Address - Street 1:701 BOB O LINK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3759
Practice Address - Country:US
Practice Address - Phone:859-277-3737
Practice Address - Fax:859-277-3765
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246302085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64246309Medicaid
KY920006560OtherRR MEDICARE
KY0930202Medicare PIN
KYE01342Medicare UPIN
KY0663901Medicare PIN
KY00588002Medicare PIN