Provider Demographics
NPI:1255402277
Name:MATISCIK, R. MARTIN (DC)
Entity type:Individual
Prefix:DR
First Name:R. MARTIN
Middle Name:
Last Name:MATISCIK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 TRAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5007
Mailing Address - Country:US
Mailing Address - Phone:330-758-6440
Mailing Address - Fax:330-758-6990
Practice Address - Street 1:914 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5007
Practice Address - Country:US
Practice Address - Phone:330-758-6440
Practice Address - Fax:330-758-6990
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2192111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0190270Medicaid
OH000000229020OtherANTHEM
OH268261599010OtherMEDICAL MUTUAL
OH000000350553OtherANTHEM
OH268261599010OtherMEDICAL MUTUAL
OH0190270Medicaid
OH000000229020OtherANTHEM