Provider Demographics
NPI:1013111749
Name:DE MATOS MAILLARD, VERA LUCIA (MD)
Entity Type:Individual
Prefix:
First Name:VERA
Middle Name:LUCIA
Last Name:DE MATOS MAILLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:100 PENN SQUARE EAST 9TH FL NORTH TOWER
Mailing Address - Street 2:CHCA GASTRO
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:267-425-9500
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-3247
Practice Address - Fax:215-590-3606
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2018-04-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4632342080P0206X
MI4301090139390200000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program