MEDICARE: DR. FERNANDO V. MATA M.D.

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	2084P0800X	Psychiatry Physician	ME0047345	FL

General Provider Information

NPI Number	:	1134279185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FERNANDO V. MATA M.D.

Provider Business Mailing Address
First Line	:	1930 N.E. 47TH ST.
Second Line	:	SUITE 309
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-7729
Country	:	US
Telephone Number	:	954-938-7011
Fax Number	:	954-938-9996

Provider Business Practice Location Address
First Line	:	2151 E COMMERCIAL BLVD
Second Line	:	SUITE 304
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-3807
Country	:	US
Telephone Number	:	954-938-7011
Fax Number	:	954-938-7019

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	11/02/2011

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