Provider Demographics
NPI:1245438704
Name:MATA, CHARLES SEDILLO (CO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SEDILLO
Last Name:MATA
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 E HATTON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4842
Mailing Address - Country:US
Mailing Address - Phone:850-449-0380
Mailing Address - Fax:
Practice Address - Street 1:4100 S FERDON BLVD
Practice Address - Street 2:B-4
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5252
Practice Address - Country:US
Practice Address - Phone:850-449-0380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORT157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5941110001Medicare NSC