Provider Demographics
NPI:1952311490
Name:MATA, CRISTINA B
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:B
Last Name:MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NW 12TH AVE
Mailing Address - Street 2:SUITE 810
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1051
Mailing Address - Country:US
Mailing Address - Phone:305-585-6649
Mailing Address - Fax:
Practice Address - Street 1:3801 BISCAYNE BLVD
Practice Address - Street 2:STE 230
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-9800
Practice Address - Country:US
Practice Address - Phone:786-466-8490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51321207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055816800Medicaid
FLE71318Medicare UPIN
FL11680XMedicare ID - Type Unspecified