Healthcare Provider Details

I. General information

NPI: 1285551721
Provider Name (Legal Business Name): SHAKEEM MATA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 SW 163RD AVE
MIRAMAR FL
33027-4452
US

IV. Provider business mailing address

1865 SW 163RD AVE
MIRAMAR FL
33027-4452
US

V. Phone/Fax

Practice location:
  • Phone: 917-288-9730
  • Fax:
Mailing address:
  • Phone: 917-288-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: