Provider Demographics
NPI:1518931377
Name:MATA, NELSON A (MD)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:A
Last Name: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 1:603 S NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-2647
Mailing Address - Country:US
Mailing Address - Phone:956-787-0669
Mailing Address - Fax:956-787-2666
Practice Address - Street 1:603 S NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-2647
Practice Address - Country:US
Practice Address - Phone:956-787-0669
Practice Address - Fax:956-787-2666
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7075207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134160406Medicaid
TX00R75NOtherBCBS
TX930043393OtherRR MEDICARE