Provider Demographics
NPI:1578503645
Name:MATZKO, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MATZKO
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:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-789-4461
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6504
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-789-4461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-006312085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC16-54620OtherUNITED HEALTHCARE
NC8954833Medicaid
NC16-54618OtherUNITED HEALTHCARE
NC64595OtherMEDCOST
NC54833OtherBLUECROSS BLUESHIELD
NC64597OtherMEDCOST
NC16-54619OtherUNITED HEALTHCARE
NC64599OtherMEDCOST
NC64595OtherMEDCOST
NC16-54620OtherUNITED HEALTHCARE
NC2224383AMedicare ID - Type Unspecified
NC2224383Medicare ID - Type Unspecified