Healthcare Provider Details

I. General information

NPI: 1396841623
Provider Name (Legal Business Name): MARIANO DE LA MATA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13506 SUMMERPORT VILLAGE PKWY #341
WINDERMERE FL
34786-7366
US

IV. Provider business mailing address

PO BOX 100186
GAINESVILLE FL
32610-0186
US

V. Phone/Fax

Practice location:
  • Phone: 865-406-9069
  • Fax:
Mailing address:
  • Phone: 352-265-5911
  • Fax: 352-265-5606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME99936
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME99936
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME99936
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19293
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number14898A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: