Provider Demographics
NPI:1285716977
Name:OTSENRE E MATOS M D P A
Entity type:Organization
Organization Name:OTSENRE E MATOS M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OTSENRE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-849-2005
Mailing Address - Street 1:PO BOX 1014
Mailing Address - Street 2:
Mailing Address - City:ELFERS
Mailing Address - State:FL
Mailing Address - Zip Code:34680-1014
Mailing Address - Country:US
Mailing Address - Phone:727-849-2005
Mailing Address - Fax:727-849-2087
Practice Address - Street 1:4821 US HIGHWAY 19 STE 1
Practice Address - Street 2:
Practice Address - City:NEW PRT RCHY
Practice Address - State:FL
Practice Address - Zip Code:34652-4259
Practice Address - Country:US
Practice Address - Phone:727-849-2005
Practice Address - Fax:727-849-2087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH4227OtherMEDICARE RAILROAD
FL162704600OtherFEDERAL WORKERS COMP
FLK1737Medicare PIN