MEDICARE: K-MATA LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1790655108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K-MATA LLC

Provider Business Mailing Address
First Line	:	3899 GRASSLAND LOOP
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-4120
Country	:	US
Telephone Number	:	770-718-1517
Fax Number	:	770-718-1518

Provider Business Practice Location Address
First Line	:	4292 CHAMBLEE TUCKER RD
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-2103
Country	:	US
Telephone Number	:	770-718-1517
Fax Number	:	770-718-1518

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BYRON OSWALDO MATA GONZALEZ
Credential	:	MD
Telephone Number	:	770-718-1517

Provider Enumeration Date	:	11/10/2025
Last Update Date	:	11/10/2025

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