Healthcare Provider Details

I. General information

NPI: 1548898018
Provider Name (Legal Business Name): KARLA DE LA MATA TARRICONE DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KARLA DE LA MATA DPM

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

IV. Provider business mailing address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-6810
  • Fax: 210-450-6021
Mailing address:
  • Phone: 210-450-6810
  • Fax: 210-450-6021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number692104
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number692104
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: