Provider Demographics
NPI:1285613109
Name:MATACZYNSKI, JAMES DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DEAN
Last Name:MATACZYNSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3805B SPRING ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1641
Mailing Address - Country:US
Mailing Address - Phone:262-634-6679
Mailing Address - Fax:262-634-7935
Practice Address - Street 1:3805B SPRING ST
Practice Address - Street 2:SUITE 250
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1641
Practice Address - Country:US
Practice Address - Phone:262-634-6679
Practice Address - Fax:262-634-7935
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI31067 020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31598100Medicaid
E59563Medicare UPIN
E59563Medicare UPIN