Provider Demographics
NPI:1417900283
Name:MATOS, MYLTHIA P (OD)
Entity type:Individual
Prefix:DR
First Name:MYLTHIA
Middle Name:P
Last Name:MATOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#3 GARDENIA BZ115 CAPE SEA VILLAGE
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:787-379-9070
Mailing Address - Fax:
Practice Address - Street 1:CALLE ANTONIO R BARCELO#8
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00954
Practice Address - Country:US
Practice Address - Phone:787-870-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR57770OtherTRIPLE S