Provider Demographics
NPI:1043526791
Name:MATIAS ROMAN, BETHZAIDA (MT)
Entity Type:Individual
Prefix:
First Name:BETHZAIDA
Middle Name:
Last Name:MATIAS ROMAN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2023
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-2023
Mailing Address - Country:US
Mailing Address - Phone:787-868-3884
Mailing Address - Fax:787-868-3884
Practice Address - Street 1:STREET 417 KM 4.2
Practice Address - Street 2:BO MAMEY
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602-2023
Practice Address - Country:US
Practice Address - Phone:787-868-3884
Practice Address - Fax:787-868-3884
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR40D2007082246QM0706X
PR6334291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist