Healthcare Provider Details

I. General information

NPI: 1265778971
Provider Name (Legal Business Name): CARLOS MATA P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 W HWY 90
CRESTVIEW FL
32536-2638
US

IV. Provider business mailing address

205 TOOKE ST
FORT WALTON BEACH FL
32547-2681
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-2260
  • Fax:
Mailing address:
  • Phone: 850-920-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME111574
License Number StateFL

VIII. Authorized Official

Name: DR. CARLOS MATA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 850-920-3223