1609135128 NPI number — FERNANDO V. MATA , MD, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609135128 NPI number — FERNANDO V. MATA , MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FERNANDO V. MATA , MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609135128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 NE 47TH ST
Provider Second Line Business Mailing Address:
SUITE 309
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-7718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-938-7011
Provider Business Mailing Address Fax Number:
954-938-9996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 NE 47TH ST
Provider Second Line Business Practice Location Address:
SUITE 309
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-7718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-938-7011
Provider Business Practice Location Address Fax Number:
954-938-9996
Provider Enumeration Date:
05/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MATA
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-938-7011

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  ME0047345 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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