Provider Demographics
NPI:1932497955
Name:MATOS SANTANA, TEOFILO ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:TEOFILO
Middle Name:ENRIQUE
Last Name:MATOS SANTANA
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 1:4175 W 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5874
Mailing Address - Country:US
Mailing Address - Phone:305-424-3118
Mailing Address - Fax:
Practice Address - Street 1:4175 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5874
Practice Address - Country:US
Practice Address - Phone:305-424-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0521822084P0800X
390200000X
FLME1613062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program