Provider Demographics
NPI:1770868416
Name:T.R. MATIONG MD PA
Entity Type:Organization
Organization Name:T.R. MATIONG MD PA
Other - Org Name:MATIONG MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:TEODULO
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATIONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:727-857-1818
Mailing Address - Street 1:10201 STATE ROAD 52
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-3071
Mailing Address - Country:US
Mailing Address - Phone:727-857-1818
Mailing Address - Fax:727-857-1609
Practice Address - Street 1:10201 STATE ROAD 52
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34669-3071
Practice Address - Country:US
Practice Address - Phone:727-857-1818
Practice Address - Fax:727-857-1609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
593613012OtherHUMANA PPO
451024515OtherWELLCARE
10624OtherBLUE CROSS BLUE SHIELD
05931OtherUHCARE
A61906Medicare UPIN