Provider Demographics
NPI:1609135128
Name:FERNANDO V. MATA , MD, PA
Entity Type:Organization
Organization Name:FERNANDO V. MATA , MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:V
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-938-7011
Mailing Address - Street 1:1930 NE 47TH ST
Mailing Address - Street 2:SUITE 309
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7718
Mailing Address - Country:US
Mailing Address - Phone:954-938-7011
Mailing Address - Fax:954-938-9996
Practice Address - Street 1:1930 NE 47TH ST
Practice Address - Street 2:SUITE 309
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7718
Practice Address - Country:US
Practice Address - Phone:954-938-7011
Practice Address - Fax:954-938-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00473452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58299Medicare UPIN