Provider Demographics
NPI:1164002135
Name:IMBERT MATOS, LICET (MD)
Entity Type:Individual
Prefix:
First Name:LICET
Middle Name:
Last Name:IMBERT MATOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 NILES ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-4922
Mailing Address - Country:US
Mailing Address - Phone:661-328-4284
Mailing Address - Fax:661-616-9977
Practice Address - Street 1:7800 NILES ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-4922
Practice Address - Country:US
Practice Address - Phone:661-328-4284
Practice Address - Fax:661-616-9977
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program