Provider Demographics
NPI:1063629673
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 1:9201 W SUNSET BLVD STE 406
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3705
Mailing Address - Country:US
Mailing Address - Phone:310-887-1730
Mailing Address - Fax:
Practice Address - Street 1:9201 W SUNSET BLVD STE 406
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-3705
Practice Address - Country:US
Practice Address - Phone:310-887-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39658207VG0400X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Not Answered2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery