Provider Demographics
NPI:1972506509
Name:MATOS, LUIS ANGEL (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANGEL
Last Name:MATOS
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13103
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24031-3103
Mailing Address - Country:US
Mailing Address - Phone:434-252-0026
Mailing Address - Fax:844-693-9305
Practice Address - Street 1:1019A VISTA PARK DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4901
Practice Address - Country:US
Practice Address - Phone:434-515-0419
Practice Address - Fax:844-693-9305
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056392208000000X, 2080P0201X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5804426Medicaid
VA5804426Medicaid