Provider Demographics
NPI:1568416030
Name:MATADIAL, JAYSHREE (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYSHREE
Middle Name:
Last Name:MATADIAL
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: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:772-337-3914
Mailing Address - Fax:772-337-3917
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:772-337-3914
Practice Address - Fax:772-337-3917
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 77972207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06190YMedicare PIN