Healthcare Provider Details

I. General information

NPI: 1972506509
Provider Name (Legal Business Name): LUIS ANGEL MATOS M.D., MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019A VISTA PARK DR
FOREST VA
24551-4901
US

IV. Provider business mailing address

PO BOX 13103
ROANOKE VA
24031-3103
US

V. Phone/Fax

Practice location:
  • Phone: 434-515-0419
  • Fax: 844-693-9305
Mailing address:
  • Phone: 434-252-0026
  • Fax: 844-693-9305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101056392
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number0101056392
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number0101056392
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: