Provider Demographics
NPI:1669577573
Name:MATEJKA, ROBERT JOHN (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:MATEJKA
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 1:2146 POWDERKEG DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1784
Mailing Address - Country:US
Mailing Address - Phone:801-944-8866
Mailing Address - Fax:
Practice Address - Street 1:3460 PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-2049
Practice Address - Country:US
Practice Address - Phone:801-993-9526
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT319892-1204207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT700OtherHEALTHY U
UT224510OtherALTIUS
UT607111900OtherUS DEPT OF LABOR
UT1020088Medicaid
UTPRA01843OtherMOLINA
UT609345OtherDESERET MUTUAL
UT107007846103OtherIHC
UT81627OtherPEHP