Provider Demographics
NPI:1134279185
Name:MATA, FERNANDO V (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:V
Last Name:MATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1930 N.E. 47TH ST.
Mailing Address - Street 2:SUITE 309
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7729
Mailing Address - Country:US
Mailing Address - Phone:954-938-7011
Mailing Address - Fax:954-938-9996
Practice Address - Street 1:2151 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3807
Practice Address - Country:US
Practice Address - Phone:954-938-7011
Practice Address - Fax:954-938-7019
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME00473452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58299Medicare UPIN
FL73259Medicare ID - Type Unspecified