Provider Demographics
NPI:1164579272
Name:MATITYAHU, ODI O (DC)
Entity Type:Individual
Prefix:
First Name:ODI
Middle Name:O
Last Name:MATITYAHU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 KITTYHAWK DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-6071
Mailing Address - Country:US
Mailing Address - Phone:972-985-1432
Mailing Address - Fax:972-985-8779
Practice Address - Street 1:3900 W 15TH ST STE 506
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-4727
Practice Address - Country:US
Practice Address - Phone:972-985-1432
Practice Address - Fax:972-985-8779
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6719111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU62630Medicare UPIN
605503Medicare ID - Type Unspecified