Basic Information
| Provider Information | |||||||||
| NPI: | 1770868416 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | T.R. MATIONG MD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MATIONG MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10201 STATE ROAD 52 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346693071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278571818 | ||||||||
| FaxNumber: | 7278571609 | ||||||||
| Practice Location | |||||||||
| Address1: | 10201 STATE ROAD 52 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346693071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278571818 | ||||||||
| FaxNumber: | 7278571609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2011 | ||||||||
| LastUpdateDate: | 07/08/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATIONG | ||||||||
| AuthorizedOfficialFirstName: | TEODULO | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 7278571818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 593613012 | 01 | HUMANA PPO | OTHER | 451024515 | 01 | WELLCARE | OTHER | 10624 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 05931 | 01 | UHCARE | OTHER |