Provider Demographics
NPI:1487641403
Name:MAETOZO, SHERRI LEE (MD)
Entity Type:Individual
Prefix:
First Name:SHERRI
Middle Name:LEE
Last Name:MAETOZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PLANTATION ISLAND DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3109
Mailing Address - Country:US
Mailing Address - Phone:904-461-5330
Mailing Address - Fax:904-461-5334
Practice Address - Street 1:1301 PLANTATION ISLAND DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:904-461-5330
Practice Address - Fax:904-461-5334
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56926207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE86137Medicare UPIN
FL10102Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER