Provider Demographics
NPI:1326206897
Name:MATA GONZALEZ, BYRON OSWALDO
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:OSWALDO
Last Name:MATA GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-5942
Mailing Address - Country:US
Mailing Address - Phone:770-718-1517
Mailing Address - Fax:
Practice Address - Street 1:175 W PINE AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750
Practice Address - Country:US
Practice Address - Phone:321-363-6529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-117456207QG0300X
AL29408207QG0300X
GA068243207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine