Healthcare Provider Details

I. General information

NPI: 1073695847
Provider Name (Legal Business Name): CYNTHIA MATA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S BROADWAY
AURORA IL
60505-4276
US

IV. Provider business mailing address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7100
  • Fax:
Mailing address:
  • Phone: 773-257-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-105163
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: