Provider Demographics
NPI:1568544807
Name:MATLOCK, KIMBERLY B (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:MATLOCK
Suffix:
Gender:F
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1601 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3703
Practice Address - Country:US
Practice Address - Phone:817-431-1450
Practice Address - Fax:817-431-0424
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0013208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140442855Medicaid
TXBALK449733OtherCCHIP PIN
TX00U87ZOtherBCBSTX GRP PIN
TX061089101Medicaid
1750369203OtherGRP NPI NUMBER
TX9361972OtherCIGNA PIN
TX7165173OtherAETNA PIN
TX18754259OtherFIRSTHEALTH PIN
TX9124436OtherPHCS PIN
TX108000100OtherFIRSTCARE PIN
TX140442806Medicaid
TX1983564OtherUHC PIN
TX8A0960OtherBCBSTX IND PIN
TX140442855Medicaid