Provider Demographics
NPI:1093788762
Name:MATLOCK, ERIC V A (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:V 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:PO BOX 502852
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-2852
Mailing Address - Country:US
Mailing Address - Phone:314-364-4200
Mailing Address - Fax:
Practice Address - Street 1:901 E 5TH ST
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3127
Practice Address - Country:US
Practice Address - Phone:636-239-8231
Practice Address - Fax:636-239-9890
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005011343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00769834OtherRAILROAD MEDICARE
MO1093788762Medicaid
MOMA1237003Medicare PIN
I137443Medicare UPIN