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General NPI Number Information
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NPI Number | 1265778971
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Entity Type | Organization
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Legal Business Name | CARLOS MATA P.A.
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Dates
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Enumeration Date | 12/27/2012
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Last Update Date | 12/27/2012
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Provider Practice Location Address
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Address Line | 424 W HWY 90
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City | CRESTVIEW
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State | FL
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Zip | 32536-2638
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Country | US
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Telephone | 850-689-2260
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Fax |
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Provider Business Mailing Address
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Address Line | 205 TOOKE ST
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-2681
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Country | US
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Telephone | 850-920-3223
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. CARLOS MATA
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Credential | M.D.
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Telephone | 850-920-3223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | ME111574
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License Number State | FL
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