MEDICARE: CYNTHIA MATA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036-105163	IL

General Provider Information

NPI Number	:	1073695847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA MATA MD

Provider Business Mailing Address
First Line	:	1501 S CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1732
Country	:	US
Telephone Number	:	773-257-6770
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 S BROADWAY
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60505-4276
Country	:	US
Telephone Number	:	708-747-7100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	12/19/2012

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