Provider Demographics
NPI:1518582899
Name:MATISHAK, CHRISTIAN MICHAEL CASSON (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:MICHAEL CASSON
Last Name:MATISHAK
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 1:5415 MAPLE AVENUE
Mailing Address - Street 2:APT 339
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235
Mailing Address - Country:US
Mailing Address - Phone:424-303-1606
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:MC 9159
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390
Practice Address - Country:US
Practice Address - Phone:214-648-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2022-02-25
Deactivation Date:2022-01-18
Deactivation Code:
Reactivation Date:2022-02-25
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXBP10072819390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program