Provider Demographics
NPI:1861472581
Name:MATOS, ESTANISLAO ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:ESTANISLAO
Middle Name:ANTONIO
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 1:20 OLIVE ST
Mailing Address - Street 2:STE 401
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-3194
Mailing Address - Country:US
Mailing Address - Phone:330-376-3105
Mailing Address - Fax:
Practice Address - Street 1:20 OLIVE ST
Practice Address - Street 2:STE 401
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-3194
Practice Address - Country:US
Practice Address - Phone:330-376-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35029796M207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0060437Medicaid
D31844Medicare UPIN
OHMA0146052Medicare ID - Type Unspecified