MEDICARE: LAURA MATA BALDERAS 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	207Q00000X	Family Medicine Physician	9091	PR

General Provider Information

NPI Number	:	1689781148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA MATA BALDERAS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 472
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00681-0472
Country	:	US
Telephone Number	:	787-690-2157
Fax Number	:	787-833-3831

Provider Business Practice Location Address
First Line	:	349 AVE HOSTOS
Second Line	:	MEDICAL EMPORIUM II SUITE A29
City	:	MAYAGUEZ
State	:	PR
Zip	:	00680-1509
Country	:	US
Telephone Number	:	787-690-2157
Fax Number	:	787-833-3831

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

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	08/18/2016

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