MEDICARE: DR. LUIS ANGEL MATOS M.D., MBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	0101056392	VA
2	2080P0201X	Pediatric Allergy/Immunology Physician	0101056392	VA
3	207KA0200X	Allergy Physician	0101056392	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972506509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS ANGEL MATOS M.D., MBA

Provider Business Mailing Address
First Line	:	PO BOX 13103
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24031-3103
Country	:	US
Telephone Number	:	434-252-0026
Fax Number	:	844-693-9305

Provider Business Practice Location Address
First Line	:	1019A VISTA PARK DR
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-4901
Country	:	US
Telephone Number	:	434-515-0419
Fax Number	:	844-693-9305

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	04/10/2018

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Directions to “ DR. LUIS ANGEL MATOS M.D., MBA” Practice Location

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