1417900283 NPI number — DR. MYLTHIA P MATOS OD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417900283 NPI number — DR. MYLTHIA P MATOS OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATOS
Provider First Name:
MYLTHIA
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1417900283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
#3 GARDENIA BZ115 CAPE SEA VILLAGE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROLINA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-379-9070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CALLE ANTONIO R BARCELO#8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOA ALTA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-870-7575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  601 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 57770 . This is a "TRIPLE S" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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