Healthcare Provider Details

I. General information

NPI: 1750736658
Provider Name (Legal Business Name): NICHOLAS MATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 DEFENSE HWY STE 300
ANNAPOLIS MD
21401-8926
US

IV. Provider business mailing address

166 DEFENSE HWY STE 300
ANNAPOLIS MD
21401-8926
US

V. Phone/Fax

Practice location:
  • Phone: 443-808-1808
  • Fax: 443-214-5356
Mailing address:
  • Phone: 443-808-1808
  • Fax: 443-214-5356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberD90988
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberD90988
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: