Provider Demographics
NPI:1629031679
Name:REYES MATOS, BETANIA (MD)
Entity Type:Individual
Prefix:
First Name:BETANIA
Middle Name:
Last Name:REYES MATOS
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 1:6675 WESTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6027
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:8803 FUTURES DR STE 9
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9076
Practice Address - Country:US
Practice Address - Phone:407-240-2361
Practice Address - Fax:407-345-8895
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN612208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIC109ZOtherMEDICARE PTAN
FL014084800Medicaid
FL612OtherFLORIDA ACN