Provider Demographics
NPI:1669675013
Name:MATOS, WILLIE R (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:R
Last Name:MATOS
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:PO BOX 8128
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-8128
Mailing Address - Country:US
Mailing Address - Phone:787-405-3071
Mailing Address - Fax:
Practice Address - Street 1:195 CALLE GAUTIER BENITEZ
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-5509
Practice Address - Country:US
Practice Address - Phone:787-745-7455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5030208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice