Provider Demographics
NPI:1396841623
Name:DE LA MATA, MARIANO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANO
Middle Name:
Last Name:DE LA MATA
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 1:1200 J D ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3494
Mailing Address - Country:US
Mailing Address - Phone:304-598-1200
Mailing Address - Fax:
Practice Address - Street 1:13506 SUMMERPORT VILLAGE PKWY
Practice Address - Street 2:#341
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-7366
Practice Address - Country:US
Practice Address - Phone:865-406-9069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99936207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3856126Medicaid
TN4102788OtherBCBS OF TENNESSEE
TN3943623Medicaid
KY64049224Medicaid
TNG74447Medicare UPIN
TN3856126Medicaid
TN3856126Medicare PIN