Provider Demographics
NPI:1093838401
Name:MATIAS, MIA BETTINA FELICIANO (MD)
Entity Type:Individual
Prefix:MS
First Name:MIA BETTINA
Middle Name:FELICIANO
Last Name:MATIAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MIA
Other - Middle Name:BETTINA
Other - Last Name:MATIAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:111 EPPERSON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3478
Mailing Address - Country:US
Mailing Address - Phone:423-745-5955
Mailing Address - Fax:423-745-6423
Practice Address - Street 1:111 EPPERSON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3478
Practice Address - Country:US
Practice Address - Phone:423-745-5955
Practice Address - Fax:423-745-6423
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD49483208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531351Medicaid