Provider Demographics
NPI:1053056507
Name:MATOI, SIMBARASHE (MB BCH BAO)
Entity Type:Individual
Prefix:MR
First Name:SIMBARASHE
Middle Name:
Last Name:MATOI
Suffix:
Gender:M
Credentials:MB BCH BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 THIRLMERE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-245-5304
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2023-02-15
Deactivation Date:2023-02-09
Deactivation Code:
Reactivation Date:2023-02-15
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEEC221082390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program