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General NPI Number Information
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NPI Number | 1790655108
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Entity Type | Organization
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Legal Business Name | K-MATA LLC
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Dates
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Enumeration Date | 11/10/2025
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Last Update Date | 11/10/2025
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Provider Practice Location Address
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Address Line | 4292 CHAMBLEE TUCKER RD
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City | TUCKER
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State | GA
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Zip | 30084-2103
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Country | US
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Telephone | 770-718-1517
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Fax | 770-718-1518
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Provider Business Mailing Address
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Address Line | 3899 GRASSLAND LOOP
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City | LAKE MARY
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State | FL
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Zip | 32746-4120
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Country | US
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Telephone | 770-718-1517
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Fax | 770-718-1518
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Authorized Official
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Title or Position | PRESIDENT
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Name | BYRON OSWALDO MATA GONZALEZ
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Credential | MD
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Telephone | 770-718-1517
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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