Provider Demographics
NPI:1568835627
Name:GAMALIEL G. MATTOS, MD
Entity Type:Organization
Organization Name:GAMALIEL G. MATTOS, MD
Other - Org Name:COMMUNITY PHYSICIAN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GAMALIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MATTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-418-2233
Mailing Address - Street 1:4001 NW 97TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2384
Mailing Address - Country:US
Mailing Address - Phone:305-418-2233
Mailing Address - Fax:305-418-2295
Practice Address - Street 1:4001 NW 97TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2384
Practice Address - Country:US
Practice Address - Phone:305-418-2233
Practice Address - Fax:305-418-2295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92002208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2778876400Medicaid
FLU6566Medicare PIN