Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0007X | Plastic Surgeon (Head & Neck) | OS7773 | FL |
NPI | 1205982931 |
---|---|
Provider Name | Dr. Herman Ricardo Matallana |
First Address | Lakeland, FL 33812-4264 |
Second Address | Lakeland, FL 33812-4264 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2007 |
Last Update Date | 26/07/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
264722200 | (05) | FL |
H66521 | (02) | FL |