Provider Demographics
NPI:1104816180
Name:MATRKA, THOMAS P (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:MATRKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W MAIN ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2170
Mailing Address - Country:US
Mailing Address - Phone:937-382-6951
Mailing Address - Fax:937-382-5081
Practice Address - Street 1:630 W MAIN ST
Practice Address - Street 2:SUITE 109
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2170
Practice Address - Country:US
Practice Address - Phone:937-382-6951
Practice Address - Fax:937-382-5081
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039905M207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0432982Medicaid
MA0447352Medicare ID - Type Unspecified
A77551Medicare UPIN