Provider Demographics
NPI:1972516656
Name:PICHARDO-MATOS, ELSA (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELSA
Middle Name:
Last Name:PICHARDO-MATOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6929 SUNSET STRIP
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313-2845
Mailing Address - Country:US
Mailing Address - Phone:954-578-0200
Mailing Address - Fax:954-578-0050
Practice Address - Street 1:6929 SUNSET STRIP
Practice Address - Street 2:SUNSET STRIP MEDICAL CENTER
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313
Practice Address - Country:US
Practice Address - Phone:954-578-0200
Practice Address - Fax:954-578-0050
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL425168Medicaid
FLME0040800OtherLICENSE
961164Medicare ID - Type Unspecified
FLME0040800OtherLICENSE