Provider Demographics
NPI:1740245067
Name:MATLOCK, MARVIN PERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:PERRY
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:PO BOX 2040
Mailing Address - Street 2:
Mailing Address - City:KAUNAKAKAI
Mailing Address - State:HI
Mailing Address - Zip Code:96748-2040
Mailing Address - Country:US
Mailing Address - Phone:808-553-5038
Mailing Address - Fax:808-553-3780
Practice Address - Street 1:30 OKI PLACE
Practice Address - Street 2:
Practice Address - City:KAUNAKAKAI
Practice Address - State:HI
Practice Address - Zip Code:96748
Practice Address - Country:US
Practice Address - Phone:808-553-5038
Practice Address - Fax:808-553-3780
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30634174400000X
HIMD17722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G306340Medicaid
CA00G306340Medicaid
CAP00173727Medicare ID - Type UnspecifiedRR MEDICARE