Provider Demographics
NPI:1881688315
Name:MATLAGA, ROMAN W (DO)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:W
Last Name:MATLAGA
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 1:15 BODINE LN
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-4047
Mailing Address - Country:US
Mailing Address - Phone:570-253-9164
Mailing Address - Fax:
Practice Address - Street 1:300 LACKAWANNA AVE STE 200
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-2001
Practice Address - Country:US
Practice Address - Phone:570-800-7515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008779L207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA814113OtherFIRST PRIORITY HEALTH
PA785660OtherBLUE SHIELD
PA001539491Medicaid
PA814113OtherFIRST PRIORITY HEALTH
PA785660OtherBLUE SHIELD