Provider Demographics
NPI:1710206925
Name:SHERRI LEE MAETOZO MD PA
Entity Type:Organization
Organization Name:SHERRI LEE MAETOZO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MAETOZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-461-5330
Mailing Address - Street 1:1301 PLANTATION ISLAND DRIVE
Mailing Address - Street 2:STE 103
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3109
Mailing Address - Country:US
Mailing Address - Phone:904-461-5330
Mailing Address - Fax:904-461-5334
Practice Address - Street 1:1301 PLANTATION ISLAND DRIVE
Practice Address - Street 2:STE 103
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3109
Practice Address - Country:US
Practice Address - Phone:904-461-5330
Practice Address - Fax:904-461-5334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056926207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE86137Medicare UPIN