Provider Demographics
NPI:1235248964
Name:MATTA, EDUARDO J (MD)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:J
Last Name:MATTA
Suffix:
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:PO BOX 301173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1173
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6411 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-704-4000
Practice Address - Fax:713-704-5734
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM74092085B0100X
WAMD000461902085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187016403OtherCSHCN
TX187016401Medicaid
TX8W2049OtherBCBS
TX187016403OtherCSHCN
TX8J8440Medicare PIN