Provider Demographics
NPI:1457572612
Name:MATOS, BRENDA ENID (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:ENID
Last Name: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:VIA ENRAMADA 40
Mailing Address - Street 2:ENTRERIOS
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-6165
Mailing Address - Country:US
Mailing Address - Phone:787-760-1171
Mailing Address - Fax:787-758-2355
Practice Address - Street 1:10 CASIA STREET
Practice Address - Street 2:VACHS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR124182084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0090066Medicare ID - Type Unspecified