Provider Demographics
NPI:1326480732
Name:MATTHIESEN, RYAN (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MATTHIESEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:940-565-2371
Mailing Address - Fax:940-565-3650
Practice Address - Street 1:1301 S BONNIE BRAE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207-2003
Practice Address - Country:US
Practice Address - Phone:940-565-2371
Practice Address - Fax:940-565-3650
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX389087302Medicaid
TX389087301Medicaid
TX8JK4671OtherBCBSTX