Provider Demographics
NPI:1336494699
Name:MATA, MARIO DAVID (LSA)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:DAVID
Last Name:MATA
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14110 HARTFORD HEIGHTS WAY
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583
Mailing Address - Country:US
Mailing Address - Phone:713-315-1519
Mailing Address - Fax:
Practice Address - Street 1:14110 HARTFORD HEIGHTS WAY
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583
Practice Address - Country:US
Practice Address - Phone:713-315-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00462363AS0400X, 246ZS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0400XSpecialist/Technologist, OtherSurgical
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8LU082OtherBCBS - UNIVERSAL SURGICAL ASSISTANTS INC
TX8LU185OtherBCBS - XCITE SURGICAL LLC
TX8LV132OtherBCBS - BLUE STAR SURGICAL ASSISTANTS LLC
TX8LT984OtherBCBS - UNIVERSAL SURGICAL PARTNERS INC
TXSA00462OtherTEXAS MEDICAL BOARD