Provider Demographics
NPI:1386739506
Name:MATIONG, TEODULO REYES (MD)
Entity type:Individual
Prefix:
First Name:TEODULO
Middle Name:REYES
Last Name:MATIONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14690 SPRING HILL DR STE 305
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:10201 SR 52
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34669
Practice Address - Country:US
Practice Address - Phone:727-857-1818
Practice Address - Fax:727-857-1609
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0028139207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL225165OtherWELLCARE
FL063426301Medicaid
FL225165OtherWELLCARE/STAYWELL
FL225165OtherWELLCARE/STAYWELL
FL10624Medicare ID - Type Unspecified