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General NPI Number Information
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NPI Number | 1134279185
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Entity Type | Individual
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Provider Name | FERNANDO V. MATA M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 11/02/2011
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Provider Practice Location Address
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Address Line | 2151 E COMMERCIAL BLVD SUITE 304
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City | FT LAUDERDALE
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State | FL
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Zip | 33308-3807
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Country | US
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Telephone | 954-938-7011
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Fax | 954-938-7019
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Provider Business Mailing Address
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Address Line | 1930 N.E. 47TH ST. SUITE 309
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City | FT LAUDERDALE
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State | FL
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Zip | 33308-7729
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Country | US
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Telephone | 954-938-7011
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Fax | 954-938-9996
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME0047345
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License Number State | FL
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