Basic Information
| Provider Information | |||||||||
| NPI: | 1164788907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATOS | ||||||||
| FirstName: | ZOILA | ||||||||
| MiddleName: | YUDITH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 E 106TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100294007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123602600 | ||||||||
| FaxNumber: | 2123602618 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 E 106TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100294007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123602600 | ||||||||
| FaxNumber: | 2123602618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2012 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 005015 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 331844 | 01 | NY | MEDICARE | OTHER | 00355151 | 05 | NY | MEDICAID |