Healthcare Provider Details

I. General information

NPI: 1992531750
Provider Name (Legal Business Name): MATMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13302 WINDING OAK CT STE A
TAMPA FL
33612-3425
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 786-808-8555
  • Fax: 786-360-1100
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: PRESIDENT
Credential: MD, MBA
Phone: 305-205-2306