Healthcare Provider Details

I. General information

NPI: 1114975851
Provider Name (Legal Business Name): BERNARDITA MATOL MAURE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAIN STREET FLORIDA STATE HOSPITAL
CHATTAHOOCHEE FL
32324-1118
US

IV. Provider business mailing address

302 FLOWERWOOD DRIVE APT 1
CHATTAHOOCHEE FL
32324
US

V. Phone/Fax

Practice location:
  • Phone: 850-663-7559
  • Fax:
Mailing address:
  • Phone: 850-663-7559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME57717
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: