Provider Demographics
NPI:1588314272
Name:HALL MATOS, LOU ANN (DPM)
Entity type:Individual
Prefix:DR
First Name:LOU ANN
Middle Name:
Last Name:HALL MATOS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E DOUGLAS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1464
Mailing Address - Country:US
Mailing Address - Phone:574-335-6800
Mailing Address - Fax:
Practice Address - Street 1:3421 CASSOPOLIS ST STE 200
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6774
Practice Address - Country:US
Practice Address - Phone:574-335-8180
Practice Address - Fax:574-335-0843
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001495A213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300064043Medicaid