Provider Demographics
NPI:1316699291
Name:MATOS, GREGORY GABOR
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:GABOR
Last Name:MATOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 VANDERBILT CIR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7342
Mailing Address - Country:US
Mailing Address - Phone:217-303-4969
Mailing Address - Fax:
Practice Address - Street 1:501 S PRESTON ST UNIT 415
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1701
Practice Address - Country:US
Practice Address - Phone:502-852-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-22
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program