Healthcare Provider Details

I. General information

NPI: 1013177807
Provider Name (Legal Business Name): DR. EMORY MATTHEW MANTEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2008
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

V. Phone/Fax

Practice location:
  • Phone: 305-689-2023
  • Fax:
Mailing address:
  • Phone: 305-689-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME124091
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License NumberME124091
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME124091
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: