Basic Information
| Provider Information | |||||||||
| NPI: | 1124281852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATA | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | BARCO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5445 PROVINE PLACE | ||||||||
| Address2: | APARTMENT 1608 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713033700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 4TH ST | ||||||||
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| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713018421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 02/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | MD203581 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1124281852 | 01 | LA | BLUE CROSS BLUE SHIELD | OTHER | 2120336 | 05 | LA | MEDICAID |