Healthcare Provider Details

I. General information

NPI: 1295056893
Provider Name (Legal Business Name): NIKOLAS MATA-MACHADO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 14TH ST APT 801
CHICAGO IL
60605-3666
US

IV. Provider business mailing address

100 E 14TH ST APT 1202
CHICAGO IL
60605-3671
US

V. Phone/Fax

Practice location:
  • Phone: 773-569-1822
  • Fax:
Mailing address:
  • Phone: 718-300-2246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number036131814
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: