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General NPI Number Information
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NPI Number | 1275518284
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Entity Type | Organization
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Legal Business Name | HERMAN R MATALLANA DO PA
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Dates
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Enumeration Date | 12/13/2005
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Last Update Date | 10/14/2008
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Provider Practice Location Address
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Address Line | 5420 STRICKLAND AVE
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City | LAKELAND
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State | FL
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Zip | 33812-4264
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Country | US
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Telephone | 863-701-9510
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Fax | 863-701-9518
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Provider Business Mailing Address
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Address Line | 5420 STRICKLAND AVE
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City | LAKELAND
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State | FL
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Zip | 33812-4264
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Country | US
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Telephone | 863-701-9510
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Fax | 863-701-9518
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. HERMAN R MATALLANA
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Credential | DO
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Telephone | 863-701-9510
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number | OS7773
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License Number State | FL
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