Provider Demographics
NPI:1538379276
Name:MATA, ROLANDO (IDC)
Entity type:Individual
Prefix:MR
First Name:ROLANDO
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 BROOKLINE DR.
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434
Mailing Address - Country:US
Mailing Address - Phone:757-444-1629
Mailing Address - Fax:
Practice Address - Street 1:4007 BROOKLINE DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-9327
Practice Address - Country:US
Practice Address - Phone:757-934-3135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical