Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 50158 | CT |
NPI | 1053696187 |
---|---|
Provider Name | Dr. Charles Christian Matouk |
First Address | New Haven, CT 06510-3206 |
Second Address | New Haven, CT 06519-1369 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2011 |
Last Update Date | 19/09/2012 |