Provider Demographics
NPI:1629057492
Name:MATYLEWICZ, ROBERT C JR (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:MATYLEWICZ
Suffix:JR
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 1:1065 NE 125TH STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5833
Mailing Address - Country:US
Mailing Address - Phone:888-852-6672
Mailing Address - Fax:305-891-4228
Practice Address - Street 1:1166 HILTS ROAD
Practice Address - Street 2:
Practice Address - City:WRIGHTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17368-9205
Practice Address - Country:US
Practice Address - Phone:888-852-6672
Practice Address - Fax:305-891-4228
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009643L207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018670440004Medicaid
PA054124N84Medicare ID - Type Unspecified
PA0018670440004Medicaid