Provider Demographics
NPI:1689781148
Name:MATA BALDERAS, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MATA BALDERAS
Suffix:
Gender:F
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:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0472
Mailing Address - Country:US
Mailing Address - Phone:787-690-2157
Mailing Address - Fax:787-833-3831
Practice Address - Street 1:349 AVE HOSTOS
Practice Address - Street 2:MEDICAL EMPORIUM II SUITE A29
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1509
Practice Address - Country:US
Practice Address - Phone:787-690-2157
Practice Address - Fax:787-833-3831
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF71139Medicare UPIN