Provider Demographics
NPI:1639121577
Name:MATAMOROS, ERNESTO (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:
Last Name:MATAMOROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4179 W 9TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7201
Mailing Address - Country:US
Mailing Address - Phone:786-282-4916
Mailing Address - Fax:
Practice Address - Street 1:1695 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7344
Practice Address - Country:US
Practice Address - Phone:305-207-4443
Practice Address - Fax:305-207-4442
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38894208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL95778OtherBC BS OF FL PROVIDER NO
FLME38894OtherFL MEDICAL LICENSE NO
FLF25121Medicare UPIN
FL95778Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO