Healthcare Provider Details

I. General information

NPI: 1285716977
Provider Name (Legal Business Name): OTSENRE E MATOS M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4821 US HIGHWAY 19 STE 1
NEW PRT RCHY FL
34652-4259
US

IV. Provider business mailing address

PO BOX 1014
ELFERS FL
34680-1014
US

V. Phone/Fax

Practice location:
  • Phone: 727-849-2005
  • Fax: 727-849-2087
Mailing address:
  • Phone: 727-849-2005
  • Fax: 727-849-2087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OTSENRE E MATOS
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: MD
Phone: 727-849-2005