Provider Demographics
NPI:1316396070
Name:MATTA, NEIL S (LDO)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:S
Last Name:MATTA
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BEACH DR NE STE 115
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3403
Mailing Address - Country:US
Mailing Address - Phone:727-800-5535
Mailing Address - Fax:727-350-3928
Practice Address - Street 1:300 BEACH DR NE STE 115
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3403
Practice Address - Country:US
Practice Address - Phone:727-800-5535
Practice Address - Fax:727-350-3928
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3942156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician