Provider Demographics
NPI:1992790851
Name:MATEOS-MORA, MIGUEL (MD,)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:MATEOS-MORA
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 1:6700 STILL POINT DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2033
Mailing Address - Country:US
Mailing Address - Phone:321-254-1611
Mailing Address - Fax:321-254-3166
Practice Address - Street 1:445 PINEDA CT
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7536
Practice Address - Country:US
Practice Address - Phone:321-254-1611
Practice Address - Fax:321-254-3166
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50407207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061083600Medicaid
FL08522AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER