Provider Demographics
NPI:1881679819
Name:MATICK, HENRY J (DO)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:J
Last Name:MATICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1069
Mailing Address - Country:US
Mailing Address - Phone:812-886-6608
Mailing Address - Fax:812-882-3008
Practice Address - Street 1:621 S 7TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1069
Practice Address - Country:US
Practice Address - Phone:812-886-6608
Practice Address - Fax:812-882-3008
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020009492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100155150Medicaid
IN100155150Medicaid
IN443420Medicare ID - Type Unspecified