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General NPI Number Information
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NPI Number | 1477888444
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Entity Type | Organization
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Legal Business Name | GASTROENTEROLOGY SPECIALIST OF THE TREASURE COAST, INC
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Dates
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Enumeration Date | 10/08/2009
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Last Update Date | 05/26/2020
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Provider Practice Location Address
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Address Line | 501 NW LAKE WHITNEY PL STE 102
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-1615
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Country | US
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Telephone | 772-359-0091
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8090
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City | PORT ST LUCIE
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State | FL
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Zip | 34985-8090
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Country | US
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Telephone | 772-359-0091
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAYSHREE MATADIAL
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Credential | M.D.
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Telephone | 772-359-0091
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | ME77972
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License Number State | FL
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