Provider Demographics
NPI:1215372578
Name:KROLIKOWSKI, MATTHEW RYAN (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:KROLIKOWSKI
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 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-433-6039
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:4 SHERIDAN SQ STE 200
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-246-7931
Practice Address - Fax:423-246-1906
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3069207RI0200X, 207R00000X
VA0102204541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1215372578Medicaid
TNQ025295Medicaid
TNQ025295Medicaid
TN103I115074Medicare PIN