Provider Demographics
NPI:1295056893
Name:MATA-MACHADO, NIKOLAS (MD)
Entity type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:
Last Name:MATA-MACHADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 14TH ST APT 1202
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3671
Mailing Address - Country:US
Mailing Address - Phone:718-300-2246
Mailing Address - Fax:
Practice Address - Street 1:100 E 14TH ST APT 801
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3666
Practice Address - Country:US
Practice Address - Phone:773-569-1822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361318142080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036131814Medicaid