Basic Information
Provider Information | |||||||||
NPI: | 1790920775 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATOS | ||||||||
FirstName: | MIGUEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO, MBA, MHA, MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 RIVERSIDE CIR | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240164955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5402245170 | ||||||||
FaxNumber: | 5409838212 | ||||||||
Practice Location | |||||||||
Address1: | 3 RIVERSIDE CIR | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240164955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5402245170 | ||||||||
FaxNumber: | 5409838212 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2008 | ||||||||
LastUpdateDate: | 08/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | 0102205056 | VA | Y |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 2867 | WV | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208D00000X | OT012535 | PA | N |   | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.