Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 0401411071 | VA |
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 25MA10294300 | NJ |
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 36041 | AL |
N | 207Y00000X | Otolaryngologist (ENT Doctor) | Q0461 | TX |
Y | 207YX0007X | Plastic Surgeon (Head & Neck) | 25MA10294300 | NJ |
NPI | 1114065406 |
---|---|
Provider Name | Dr. Matin Mikayil Imanguli |
First Address | New Brunswick, NJ 08901-1962 |
Second Address | New Brunswick, NJ 08901-1962 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2007 |
Last Update Date | 31/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
113660124 | TAX IDENTIFICATION (01) | VA |
542034392 | TAX IDENTIFICATION (01) | VA |
841629676 | TAX IDENTIFICATION (01) | VA |