Provider Demographics
NPI:1205337201
Name:MATLI, JANTZEN (DO)
Entity type:Individual
Prefix:
First Name:JANTZEN
Middle Name:
Last Name:MATLI
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 1:1507 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-1024
Mailing Address - Country:US
Mailing Address - Phone:254-865-2166
Mailing Address - Fax:254-248-0626
Practice Address - Street 1:1507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-1024
Practice Address - Country:US
Practice Address - Phone:254-865-2166
Practice Address - Fax:254-248-0626
Is Sole Proprietor?:No
Enumeration Date:2018-02-24
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT1459207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine