Healthcare Provider Details

I. General information

NPI: 1366623704
Provider Name (Legal Business Name): ANGELA FAY MATA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA FAY MATA-ANGELOCCI MD

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD STE 270
DETROIT MI
48236-2175
US

IV. Provider business mailing address

22201 MOROSS RD STE 270
DETROIT MI
48236-2175
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-3481
  • Fax: 313-343-7937
Mailing address:
  • Phone: 313-343-3481
  • Fax: 313-343-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301086164
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35097933
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: