Provider Demographics
NPI:1558576702
Name:MATTOS, KEVIN RICHARD (IDC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RICHARD
Last Name:MATTOS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4674 CERNY RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-2753
Mailing Address - Country:US
Mailing Address - Phone:850-341-0754
Mailing Address - Fax:228-871-2135
Practice Address - Street 1:MARVIN SHIELDS BLVD
Practice Address - Street 2:CBC GULFPORT
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-0000
Practice Address - Country:US
Practice Address - Phone:850-341-0754
Practice Address - Fax:228-871-2135
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman