Basic Information
Provider Information | |||||||||
NPI: | 1053437327 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MATOWAKAN LABORATORIES INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 779 | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261020779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044856563 | ||||||||
FaxNumber: | 3044854466 | ||||||||
Practice Location | |||||||||
Address1: | 1824 MURDOCH AVE | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261013230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044856563 | ||||||||
FaxNumber: | 3044854466 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GODFREY | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3044856563 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZF0201X |   | WV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology | 207ZP0102X |   | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.