Provider Demographics
NPI:1649771106
Name:STANLEY J MATYASIK DO PC
Entity Type:Organization
Organization Name:STANLEY J MATYASIK DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATYASIK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:240-964-8640
Mailing Address - Street 1:12502 WILLOWBROOK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6567
Mailing Address - Country:US
Mailing Address - Phone:240-964-8640
Mailing Address - Fax:301-722-2785
Practice Address - Street 1:12502 WILLOWBROOK RD STE 400
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6567
Practice Address - Country:US
Practice Address - Phone:240-964-8640
Practice Address - Fax:301-722-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0053855207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty