Provider Demographics
NPI:1215971916
Name:MATIN, SURENA F (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:SURENA
Middle Name:F
Last Name:MATIN
Suffix:
Gender:M
Credentials:MD, FACS
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 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4561174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153851401Medicaid
TX340020494OtherRR MEDICARE
TX8F0662OtherBCBS
TX8A0598Medicare PIN
TXH15546Medicare UPIN