1285716977 NPI number — OTSENRE E MATOS M D P A

Table of content: (NPI 1285716977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285716977 NPI number — OTSENRE E MATOS M D P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTSENRE E MATOS M D P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285716977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1014
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELFERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34680-1014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-849-2005
Provider Business Mailing Address Fax Number:
727-849-2087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4821 US HIGHWAY 19 STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PRT RCHY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34652-4259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-849-2005
Provider Business Practice Location Address Fax Number:
727-849-2087
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATOS
Authorized Official First Name:
OTSENRE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
727-849-2005

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CH4227 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 162704600 . This is a "FEDERAL WORKERS COMP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com