Provider Demographics
NPI:1588847099
Name:RODRIGO B MATA III, M.D., S.C.
Entity Type:Organization
Organization Name:RODRIGO B MATA III, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:B
Authorized Official - Last Name:MATA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:262-652-2710
Mailing Address - Street 1:6123 GREEN BAY RD STE 120
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-652-2710
Mailing Address - Fax:262-652-1370
Practice Address - Street 1:6123 GREEN BAY RD STE 120
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-652-2710
Practice Address - Fax:262-652-1370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33893207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21286100Medicaid
WI21286100Medicaid