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General NPI Number Information
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NPI Number | 1396841623
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Entity Type | Individual
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Provider Name | MARIANO DE LA MATA M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 12/18/2025
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Provider Practice Location Address
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Address Line | 13506 SUMMERPORT VILLAGE PKWY #341
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City | WINDERMERE
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State | FL
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Zip | 34786-7366
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Country | US
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Telephone | 865-406-9069
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 100186
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City | GAINESVILLE
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State | FL
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Zip | 32610-0186
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Country | US
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Telephone | 352-265-5911
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Fax | 352-265-5606
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | ME99936
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME99936
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME99936
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 19293
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License Number State | WV
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Taxonomy #5
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 14898A
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License Number State | WY
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