Provider Demographics
NPI:1477888444
Name:GASTROENTEROLOGY SPECIALIST OF THE TREASURE COAST, INC
Entity Type:Organization
Organization Name:GASTROENTEROLOGY SPECIALIST OF THE TREASURE COAST, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYSHREE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATADIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-359-0091
Mailing Address - Street 1:PO BOX 8090
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-8090
Mailing Address - Country:US
Mailing Address - Phone:772-359-0091
Mailing Address - Fax:
Practice Address - Street 1:501 NW LAKE WHITNEY PL STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1615
Practice Address - Country:US
Practice Address - Phone:772-359-0091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77972207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME77972OtherMEDICAL LICENCE