Provider Demographics
NPI:1073207353
Name:MATICHAK, MARY ELISE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELISE
Last Name:MATICHAK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4751 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-4133
Mailing Address - Country:US
Mailing Address - Phone:850-503-1448
Mailing Address - Fax:
Practice Address - Street 1:4751 BEACH RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-4133
Practice Address - Country:US
Practice Address - Phone:850-503-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program