Provider Demographics
NPI:1104127372
Name:MATA, RODRIGO A JR (MD)
Entity type:Individual
Prefix:
First Name:RODRIGO
Middle Name:A
Last Name:MATA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6123 GREEN BAY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-652-6995
Mailing Address - Fax:262-652-1370
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-652-6995
Practice Address - Fax:262-652-1370
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22023-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine