Provider Demographics
NPI:1265481618
Name:MATTOS, GAMALIEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:GAMALIEL
Middle Name:G
Last Name:MATTOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GAMALIEL
Other - Middle Name:G
Other - Last Name:MATTOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4001 NW 97TH AVE
Mailing Address - Street 2:SUITE101
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2384
Mailing Address - Country:US
Mailing Address - Phone:305-436-7988
Mailing Address - Fax:305-436-3021
Practice Address - Street 1:4001 NW 97TH AVE
Practice Address - Street 2:SUITE101
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2384
Practice Address - Country:US
Practice Address - Phone:305-436-7988
Practice Address - Fax:305-436-3021
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92002207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI46661Medicare UPIN
FLU6566Medicare PIN