Provider Demographics
NPI:1538788732
Name:MATZKE, DYLAN SUPAK
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:SUPAK
Last Name:MATZKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DYLAN
Other - Middle Name:NICOLE
Other - Last Name:SUPAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:
Practice Address - Street 1:800 SCOTT AND WHITE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6440
Practice Address - Country:US
Practice Address - Phone:979-207-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV9938208800000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208800000XAllopathic & Osteopathic PhysiciansUrology