Healthcare Provider Details

I. General information

NPI: 1083611214
Provider Name (Legal Business Name): YADIRA G MATEO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 CALLE BIANCA URB TERRA SENORIAL
PONCE PR
00731-9564
US

IV. Provider business mailing address

172 CALLE BIANCA URB TERRA SENORIAL
PONCE PR
00731-9564
US

V. Phone/Fax

Practice location:
  • Phone: 787-365-0498
  • Fax:
Mailing address:
  • Phone: 787-365-0498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number11774
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: