Provider Demographics
NPI:1053354738
Name:MATOS GUADALUPE, ALBERT
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:
Last Name:MATOS GUADALUPE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12171 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8001
Mailing Address - Country:US
Mailing Address - Phone:305-278-0200
Mailing Address - Fax:
Practice Address - Street 1:400 E DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-3866
Practice Address - Country:US
Practice Address - Phone:813-308-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13389208D00000X
FLACN1252208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0020318Medicare ID - Type Unspecified
H35850Medicare UPIN