Provider Demographics
NPI:1679102131
Name:MATIENZO, DANIEL EDUARDO
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:EDUARDO
Last Name:MATIENZO
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 1:1701 W SANTA CRUZ ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2725
Mailing Address - Country:US
Mailing Address - Phone:307-286-3210
Mailing Address - Fax:
Practice Address - Street 1:8201 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2701
Practice Address - Country:US
Practice Address - Phone:964-723-1207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program