| Rodrigo B Mata Iii, M.d., S.c. | |
|
6123 Green Bay Rd Ste 120 Kenosha WI 53142-2927 | |
| (262) 652-2710 | |
| (262) 652-1370 |
| Full Name | Rodrigo B Mata Iii, M.d., S.c. |
|---|---|
| Speciality | Internal Medicine |
| Location | 6123 Green Bay Rd Ste 120, Kenosha, Wisconsin |
| Authorized Official Name and Position | Rodrigo B Mata (M.D.) |
| Authorized Official Contact | 2626522710 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Rodrigo B Mata Iii, M.d., S.c. 6123 Green Bay Rd Ste 120 Kenosha WI 53142-2927 Ph: (262) 652-2710 | Rodrigo B Mata Iii, M.d., S.c. 6123 Green Bay Rd Ste 120 Kenosha WI 53142-2927 Ph: (262) 652-2710 |
| NPI Number | 1588847099 |
|---|---|
| Provider Enumeration Date | 12/07/2007 |
| Last Update Date | 06/03/2020 |
| Medicare PECOS PAC ID | 9133024789 |
|---|---|
| Medicare Enrollment ID | O20031205000346 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1588847099 | NPI | - | NPPES |
| 21286100 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 33893 (Wisconsin) | Primary |
| Provider Name | Rodrigo B Mata |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1033148176 PECOS PAC ID: 6103721766 Enrollment ID: I20031211000097 |
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