Provider Demographics
NPI:1437452539
Name:DAVID J. MATA, M.D., INC
Entity Type:Organization
Organization Name:DAVID J. MATA, M.D., INC
Other - Org Name:DAVID J MATA, M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:951-765-1727
Mailing Address - Street 1:255 N GILBERT ST
Mailing Address - Street 2:BUILDING B, SUITE A
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4066
Mailing Address - Country:US
Mailing Address - Phone:951-765-1727
Mailing Address - Fax:951-929-3601
Practice Address - Street 1:255 N GILBERT ST
Practice Address - Street 2:BUILDING B, SUITE A
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4066
Practice Address - Country:US
Practice Address - Phone:951-765-1727
Practice Address - Fax:951-929-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64183261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G641830Medicaid
CAE59249Medicare UPIN