Provider Demographics
NPI:1033148176
Name:MATA, RODRIGO BUENCAMINO III (MD)
Entity Type:Individual
Prefix:DR
First Name:RODRIGO
Middle Name:BUENCAMINO
Last Name:MATA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6123 GREEN BAY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-652-2710
Mailing Address - Fax:
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-652-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33893207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI508901078009OtherBC/BS
WI21286100Medicaid
WI110073919Medicare PIN
WI21286100Medicaid
WI000146031Medicare PIN