Provider Demographics
NPI:1114911369
Name:MATWIJIW, IGOR EVAN (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:EVAN
Last Name:MATWIJIW
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:2602 SAINT MICHAEL DR STE 201B
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2320
Practice Address - Country:US
Practice Address - Phone:903-614-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4910207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200298690AMedicaid
TX126488902Medicaid
TX460002032OtherRAILROAD MEDICARE
TX126488906Medicaid
TX4321815OtherAETNA
TX87592ZOtherHMO BLUE
TX87281JOtherBCBS
TX4321815OtherAETNA
TX460002032OtherRAILROAD MEDICARE