Provider Demographics
NPI:1124346184
Name:MATA, JOHN ALBERT
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALBERT
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 1:3426 LAWN VW
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1702
Mailing Address - Country:US
Mailing Address - Phone:361-687-4613
Mailing Address - Fax:
Practice Address - Street 1:5610 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:ROBSTOWN
Practice Address - State:TX
Practice Address - Zip Code:78380-9496
Practice Address - Country:US
Practice Address - Phone:361-687-4613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications