Provider Demographics
NPI:1326480732
Name:MATTHIESEN, RYAN (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MATTHIESEN
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 2078
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6156
Mailing Address - Country:US
Mailing Address - Phone:817-500-9636
Mailing Address - Fax:817-439-8107
Practice Address - Street 1:2301 S FM 51 STE 100
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3864
Practice Address - Country:US
Practice Address - Phone:940-626-8810
Practice Address - Fax:940-626-8811
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8JK4671OtherBCBSTX
TX389087301Medicaid
TX389087302Medicaid