Provider Demographics
NPI:1679553481
Name:MATOS, OTSENRE E (MD)
Entity Type:Individual
Prefix:
First Name:OTSENRE
Middle Name:E
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 1014
Mailing Address - Street 2:
Mailing Address - City:ELFERS
Mailing Address - State:FL
Mailing Address - Zip Code:34680-1014
Mailing Address - Country:US
Mailing Address - Phone:727-849-2005
Mailing Address - Fax:727-849-2087
Practice Address - Street 1:4821 US HIGHWAY 19 STE 1
Practice Address - Street 2:
Practice Address - City:NEW PRT RCHY
Practice Address - State:FL
Practice Address - Zip Code:34652-4259
Practice Address - Country:US
Practice Address - Phone:727-849-2005
Practice Address - Fax:727-849-2087
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00228652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL92235OtherBLUE CROSS BLUE SHIELD
FLD59999Medicare UPIN
FL92235ZMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL