Provider Demographics
NPI:1063210722
Name:DE LA GARZA, MATILDA
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:
Last Name:DE LA GARZA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WHITE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-8307
Mailing Address - Country:US
Mailing Address - Phone:580-716-5565
Mailing Address - Fax:
Practice Address - Street 1:101 WHITE EAGLE DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-8307
Practice Address - Country:US
Practice Address - Phone:580-762-3421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator