Provider Demographics
NPI:1265845861
Name:MATTOS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:MATTOS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-871-2950
Mailing Address - Street 1:8315 N SAULRAY ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-2770
Mailing Address - Country:US
Mailing Address - Phone:813-871-2950
Mailing Address - Fax:813-871-5972
Practice Address - Street 1:8315 N SAULRAY ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-2770
Practice Address - Country:US
Practice Address - Phone:813-871-2950
Practice Address - Fax:813-871-5972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center