Provider Demographics
NPI:1124281852
Name:MATA, MARVIN BARCO (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:BARCO
Last Name:MATA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:337-470-2605
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4600 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6902
Practice Address - Country:US
Practice Address - Phone:337-470-2605
Practice Address - Fax:337-470-4595
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD2035812080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2120336Medicaid
LA1124281852OtherBLUE CROSS BLUE SHIELD