MEDICARE: DR. ELENITA P SANTOS-MATA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	07399R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053454108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELENITA P SANTOS-MATA M.D.

Provider Business Mailing Address
First Line	:	4851 W PARK DR
Second Line	:	SUITE A
City	:	ZACHARY
State	:	LA
Zip	:	70791-4010
Country	:	US
Telephone Number	:	225-658-7636
Fax Number	:	225-658-7634

Provider Business Practice Location Address
First Line	:	4851 W PARK DR
Second Line	:	SUITE A
City	:	ZACHARY
State	:	LA
Zip	:	70791-4010
Country	:	US
Telephone Number	:	225-658-7636
Fax Number	:	225-658-7634

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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