=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861785503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS ABRAHAM MATA M.D,
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2011
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 HAWKINS BLVD STE 2A
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79925-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-771-8346
-----------------------------------------------------
Fax | 915-771-8347
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 HAWKINS BLVD STE 2A
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79925-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-771-8346
-----------------------------------------------------
Fax | 915-771-8347
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | BP10040259
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 140604
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | R9252
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------