Provider Demographics
NPI:1487346102
Name:MATMED LLC
Entity type:Organization
Organization Name:MATMED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:TELLERIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:786-808-8555
Mailing Address - Street 1:9066 SW 73RD CT PH 2404
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2972
Mailing Address - Country:US
Mailing Address - Phone:786-808-8555
Mailing Address - Fax:786-360-1100
Practice Address - Street 1:7791 NW 146TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1567
Practice Address - Country:US
Practice Address - Phone:786-808-8555
Practice Address - Fax:305-967-8497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103418701Medicaid