Provider Demographics
NPI:1972735389
Name:MATTOS, KENNETH M (AP, DOM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:MATTOS
Suffix:
Gender:M
Credentials:AP, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 W TAMPA BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6615
Mailing Address - Country:US
Mailing Address - Phone:813-871-2950
Mailing Address - Fax:813-871-5972
Practice Address - Street 1:4912 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-1402
Practice Address - Country:US
Practice Address - Phone:813-871-2950
Practice Address - Fax:813-871-5972
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2738171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist