Provider Demographics
NPI:1578321667
Name:MATOS WILSON, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MATOS WILSON
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 1:12036 SW 42ND ST APT 303
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-7982
Mailing Address - Country:US
Mailing Address - Phone:305-479-1145
Mailing Address - Fax:
Practice Address - Street 1:12036 SW 42ND ST APT 303
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-7982
Practice Address - Country:US
Practice Address - Phone:305-479-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator