Healthcare Provider Details

I. General information

NPI: 1093634131
Provider Name (Legal Business Name): OMAR ALI AHMED MATAMOROS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 SW 67TH AVE APT 909
PINECREST FL
33156-1100
US

IV. Provider business mailing address

8600 SW 67TH AVE APT 909
PINECREST FL
33156-1100
US

V. Phone/Fax

Practice location:
  • Phone: 305-990-3822
  • Fax:
Mailing address:
  • Phone: 305-990-3822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9700047
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: