Basic Information
Provider Information | |||||||||
NPI: | 1174938658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATAR | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | SAMIR | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16001 W. NINE MILE RD. | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 48075 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488498483 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 210 N LAFAYETTE STREET | ||||||||
Address2: |   | ||||||||
City: | SOUTH LYON | ||||||||
State: | MI | ||||||||
PostalCode: | 48178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484371744 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2014 | ||||||||
LastUpdateDate: | 02/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 01/29/2015 | ||||||||
NPIReactivationDate: | 02/20/2015 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301105952 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.