Provider Demographics
NPI:1104654482
Name:MATA, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 E SANTA GERTRUDIS ST
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78363-4532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-5046
Practice Address - Country:US
Practice Address - Phone:361-664-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist