Provider Demographics
NPI:1043887524
Name:MATA, MARLEN SARAS (OD)
Entity type:Individual
Prefix:
First Name:MARLEN
Middle Name:SARAS
Last Name:MATA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:925 COUNTY ROAD 3822
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3107 TPC PKWY STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-2396
Practice Address - Country:US
Practice Address - Phone:210-315-5559
Practice Address - Fax:210-988-2999
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND798152W00000X
TX10351T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist