Provider Demographics
NPI:1639170830
Name:MATLOCK, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MATLOCK
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 1:8711 VILLAGE DR STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5419
Mailing Address - Country:US
Mailing Address - Phone:210-297-2244
Mailing Address - Fax:210-297-2257
Practice Address - Street 1:11503 NW MILITARY HWY
Practice Address - Street 2:SUITE 321
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78231-1884
Practice Address - Country:US
Practice Address - Phone:210-492-1677
Practice Address - Fax:210-492-1877
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5644207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24660Medicare UPIN