Provider Demographics
NPI:1396723623
Name:MATLOCK, GREGORY A (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:MATLOCK
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 1:3600 30TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5753
Mailing Address - Country:US
Mailing Address - Phone:515-699-5999
Mailing Address - Fax:
Practice Address - Street 1:3600 30TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5753
Practice Address - Country:US
Practice Address - Phone:515-699-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3121640Medicaid
IA080178754OtherRR MEDICARE
IA2121640Medicaid
IA4121640Medicaid
IA4121640Medicaid
IA080178754OtherRR MEDICARE