Provider Demographics
NPI:1205982931
Name:MATALLANA, HERMAN RICARDO (DO)
Entity type:Individual
Prefix:DR
First Name:HERMAN
Middle Name:RICARDO
Last Name:MATALLANA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 STRICKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4264
Mailing Address - Country:US
Mailing Address - Phone:863-701-9510
Mailing Address - Fax:863-701-9518
Practice Address - Street 1:5420 STRICKLAND AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4264
Practice Address - Country:US
Practice Address - Phone:863-701-9510
Practice Address - Fax:863-701-9518
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7773207YX0007X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264722200Medicaid
FL17406Medicare ID - Type UnspecifiedPROVIDER #
FLH66521Medicare UPIN