Provider Demographics
NPI:1760833636
Name:MATIASZ, RICHARD ALEXANDER (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALEXANDER
Last Name:MATIASZ
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 1:676 N ST CLAIR STREET
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-695-0700
Mailing Address - Fax:312-695-0063
Practice Address - Street 1:251 EAST HURON STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-695-0070
Practice Address - Fax:312-695-0063
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2017-03-09
Deactivation Date:2017-02-02
Deactivation Code:
Reactivation Date:2017-03-09
Provider Licenses
StateLicense IDTaxonomies
IL125069614207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program