Provider Demographics
NPI:1275518284
Name:HERMAN R MATALLANA DO PA
Entity Type:Organization
Organization Name:HERMAN R MATALLANA DO PA
Other - Org Name:FAMILY CARE ENT & REC. SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATALLANA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:863-701-9510
Mailing Address - Street 1:5420 STRICKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4264
Mailing Address - Country:US
Mailing Address - Phone:863-701-9510
Mailing Address - Fax:863-701-9518
Practice Address - Street 1:5420 STRICKLAND AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4264
Practice Address - Country:US
Practice Address - Phone:863-701-9510
Practice Address - Fax:863-701-9518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7773207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL208891OtherHEALTHEASE
FL227021OtherAMERIGROUP
FL264722200Medicaid
FL9261729OtherPHCS PRIVATE HEALTHCARE
FLV0004901OtherCITRUSCAID
FL287598OtherAVMED
FLN208891OtherSTAYWELL
FL=========OtherTAX ID
FL264722200Medicaid
FLN208891OtherSTAYWELL