Provider Demographics
NPI:1639304116
Name:CAROLYN A MATZINGER MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CAROLYN A MATZINGER MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATZINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-380-1974
Mailing Address - Street 1:10620 SOUTHERN HIGHLANDS PKWY
Mailing Address - Street 2:SUITE 110-419
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-4371
Mailing Address - Country:US
Mailing Address - Phone:702-380-1974
Mailing Address - Fax:702-269-5547
Practice Address - Street 1:1800 SPRING RIDGE DR
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-6100
Practice Address - Country:US
Practice Address - Phone:530-252-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC50852OtherCALIFORNIA MEDICAL LICENSE
NV10187OtherMEDICAL LICENSE