Provider Demographics
NPI:1710090311
Name:MATZENAUER, ALES (MD)
Entity Type:Individual
Prefix:MR
First Name:ALES
Middle Name:
Last Name:MATZENAUER
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 1:7511 CUSTER RD W
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8138
Mailing Address - Country:US
Mailing Address - Phone:253-473-7303
Mailing Address - Fax:253-473-7304
Practice Address - Street 1:7511 CUSTER RD W
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8138
Practice Address - Country:US
Practice Address - Phone:253-473-7303
Practice Address - Fax:253-473-7304
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0288165OtherSTATE L&I
WA1180082Medicaid
WA001001764Medicare PIN
E17487Medicare UPIN
WA1180082Medicaid