Provider Demographics
NPI:1861785503
Name:MATA, LUIS ABRAHAM (MD,)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ABRAHAM
Last Name:MATA
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1111 HAWKINS BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-6400
Mailing Address - Country:US
Mailing Address - Phone:915-771-8346
Mailing Address - Fax:915-771-8347
Practice Address - Street 1:1111 HAWKINS BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-6400
Practice Address - Country:US
Practice Address - Phone:915-771-8346
Practice Address - Fax:915-771-8347
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXBP10040259208600000X
FL1406042086S0129X
TXR92522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery