Provider Demographics
NPI:1881693018
Name:MATA, ISRAEL (MD)
Entity type:Individual
Prefix:
First Name:ISRAEL
Middle Name:
Last Name:MATA
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 1:105 E POLK AVE
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-3110
Mailing Address - Country:US
Mailing Address - Phone:956-781-6591
Mailing Address - Fax:956-702-0185
Practice Address - Street 1:105 E POLK AVE
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-3110
Practice Address - Country:US
Practice Address - Phone:956-781-6591
Practice Address - Fax:956-702-0185
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2017-05-14
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
TXJ2456208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121107003Medicaid
TX121107006Medicaid
TX121107001Medicaid
TX121107003Medicaid