Provider Demographics
NPI:1558445924
Name:MATA, FIDEL (PA)
Entity Type:Individual
Prefix:
First Name:FIDEL
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E LAKE SHORE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3800
Mailing Address - Country:US
Mailing Address - Phone:217-422-6100
Mailing Address - Fax:833-784-5326
Practice Address - Street 1:1770 E LAKE SHORE DR STE 105
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3800
Practice Address - Country:US
Practice Address - Phone:217-422-6100
Practice Address - Fax:833-784-5326
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.002235207RC0000X
IL085-002235363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid
ILP78585Medicare UPIN