Provider Demographics
NPI:1558327023
Name:MATEO, MARIE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ELIZABETH
Last Name:MATEO
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 1:788 RANDALL DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-4854
Mailing Address - Country:US
Mailing Address - Phone:917-373-1886
Mailing Address - Fax:
Practice Address - Street 1:500 KIRTS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-824-6060
Practice Address - Fax:248-686-0772
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222940207Q00000X
MI4301082659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02351068Medicaid
NY02351068Medicaid
MI0P30630644Medicare PIN
MI0P30630644Medicare PIN