Healthcare Provider Details

I. General information

NPI: 1487346102
Provider Name (Legal Business Name): MATMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 09/16/2023
Certification Date: 09/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7791 NW 146TH ST
MIAMI LAKES FL
33016-1567
US

IV. Provider business mailing address

9066 SW 73RD CT PH 2404
MIAMI FL
33156-2972
US

V. Phone/Fax

Practice location:
  • Phone: 786-808-8555
  • Fax: 305-967-8497
Mailing address:
  • Phone: 786-808-8555
  • Fax: 786-360-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL ANGEL TELLERIA
Title or Position: OWNER
Credential: MD, MBA
Phone: 786-808-8555