Provider Demographics
NPI:1023128444
Name:MATOS, EUGENIO B (MD)
Entity type:Individual
Prefix:
First Name:EUGENIO
Middle Name:B
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 W 18TH ST
Practice Address - Street 2:STE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-9890
Practice Address - Country:US
Practice Address - Phone:605-312-8500
Practice Address - Fax:605-312-8501
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3911174400000X, 2084N0400X
MN41998174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00413352Medicare PIN
A62959Medicare UPIN
SDS101932Medicare PIN