Provider Demographics
NPI:1194709725
Name:MATIAS, ANNABELLE M (MD)
Entity type:Individual
Prefix:
First Name:ANNABELLE
Middle Name:M
Last Name:MATIAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1689 EAGLE HARBOR PKWY E
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4817
Mailing Address - Country:US
Mailing Address - Phone:904-269-1366
Mailing Address - Fax:904-264-9750
Practice Address - Street 1:1689 EAGLE HARBOR PKWY E
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4817
Practice Address - Country:US
Practice Address - Phone:904-269-1366
Practice Address - Fax:904-264-9750
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267354100Medicaid
FLH91382Medicare UPIN
FL267354100Medicaid