Healthcare Provider Details

I. General information

NPI: 1275518284
Provider Name (Legal Business Name): HERMAN R MATALLANA DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 STRICKLAND AVE
LAKELAND FL
33812-4264
US

IV. Provider business mailing address

5420 STRICKLAND AVE
LAKELAND FL
33812-4264
US

V. Phone/Fax

Practice location:
  • Phone: 863-701-9510
  • Fax: 863-701-9518
Mailing address:
  • Phone: 863-701-9510
  • Fax: 863-701-9518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberOS7773
License Number StateFL

VIII. Authorized Official

Name: DR. HERMAN R MATALLANA
Title or Position: PRESIDENT
Credential: DO
Phone: 863-701-9510