Provider Demographics
NPI:1609040229
Name:CORREA- MATEO, LIDZOE (MD)
Entity type:Individual
Prefix:
First Name:LIDZOE
Middle Name:
Last Name:CORREA- MATEO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5985 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2533
Mailing Address - Country:US
Mailing Address - Phone:863-644-8459
Mailing Address - Fax:
Practice Address - Street 1:5985 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2533
Practice Address - Country:US
Practice Address - Phone:863-644-8459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN895208D00000X
PR17095208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN895OtherFLORIDA LICENSE