Provider Demographics
NPI:1689668832
Name:MATON, BRUNO MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:BRUNO
Middle Name:MICHAEL
Last Name:MATON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 S SPIGEL DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1817
Mailing Address - Country:US
Mailing Address - Phone:757-416-4886
Mailing Address - Fax:
Practice Address - Street 1:2881 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-5411
Practice Address - Country:US
Practice Address - Phone:407-652-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1698812084E0001X
NY2347442084N0400X
VA01012432292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02623756Medicaid
NYRA5886Medicare ID - Type Unspecified
NYI25833Medicare UPIN