Provider Demographics
NPI:1528053485
Name:MATLOCK, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MATLOCK
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 1:105 TEKE BURTON DR
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-1208
Mailing Address - Country:US
Mailing Address - Phone:812-849-3408
Mailing Address - Fax:812-849-5630
Practice Address - Street 1:105 TEKE BURTON DR
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-1208
Practice Address - Country:US
Practice Address - Phone:812-849-3408
Practice Address - Fax:812-849-5630
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057687A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200421390Medicaid
ININ1229009Medicare PIN
INI17417Medicare UPIN