Provider Demographics
NPI:1710198247
Name:MATULA, IVAN D (LAC, OMD,)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:D
Last Name:MATULA
Suffix:
Gender:M
Credentials:LAC, OMD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W 38TH ST
Mailing Address - Street 2:SUITE G3
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1121
Mailing Address - Country:US
Mailing Address - Phone:512-517-9830
Mailing Address - Fax:512-517-9830
Practice Address - Street 1:711 W 38TH ST
Practice Address - Street 2:SUITE G3
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1121
Practice Address - Country:US
Practice Address - Phone:512-517-9830
Practice Address - Fax:512-517-9830
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM291171100000X
TXAC00034171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist