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General NPI Number Information
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NPI Number | 1609135128
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Entity Type | Organization
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Legal Business Name | FERNANDO V. MATA , MD, PA
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Dates
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Enumeration Date | 05/04/2012
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Last Update Date | 05/04/2012
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Provider Practice Location Address
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Address Line | 1930 NE 47TH ST SUITE 309
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City | FT LAUDERDALE
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State | FL
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Zip | 33308-7718
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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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Provider Business Mailing Address
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Address Line | 1930 NE 47TH ST SUITE 309
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City | FT LAUDERDALE
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State | FL
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Zip | 33308-7718
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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 | PRESIDENT
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Name | FERNANDO V MATA
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Credential | M.D.
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Telephone | 954-938-7011
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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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