Provider Demographics
NPI:1811579857
Name:MATEO, JEFFERSON
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:MATEO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18915 BARRINGTON GROVE TRCE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2211
Mailing Address - Country:US
Mailing Address - Phone:347-567-0339
Mailing Address - Fax:
Practice Address - Street 1:18915 BARRINGTON GROVE TRCE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2211
Practice Address - Country:US
Practice Address - Phone:347-567-0339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4806246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy