Provider Demographics
NPI:1518380104
Name:MATHISON, LUIS EDUARDO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:EDUARDO
Last Name:MATHISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11217 NW 73RD ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2868
Mailing Address - Country:US
Mailing Address - Phone:305-597-0636
Mailing Address - Fax:
Practice Address - Street 1:3501 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5421
Practice Address - Country:US
Practice Address - Phone:954-265-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-02
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12751246ZC0007X
CO07-297246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant