Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 0101056392 | VA |
N | 208000000X | Pediatrician | 0101056392 | VA |
N | 2080P0201X | Pediatric Allergist | 0101056392 | VA |
NPI | 1972506509 |
---|---|
Provider Name | Dr. Luis Angel Matos |
First Address | Roanoke, VA 24031-3103 |
Second Address | Forest, VA 24551-4901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2005 |
Last Update Date | 10/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5804426 | (05) | VA |
I12188 | (02) | VA |