Provider Demographics
NPI:1700881190
Name:MATLACK, ROBERT K JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:K
Last Name:MATLACK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2587 RAVENHILL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5451
Mailing Address - Country:US
Mailing Address - Phone:910-323-1543
Mailing Address - Fax:910-485-1257
Practice Address - Street 1:2587 RAVENHILL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5451
Practice Address - Country:US
Practice Address - Phone:910-323-1543
Practice Address - Fax:910-485-1257
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002012822084P0800X
NC200212822084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC301980OtherMANAGED HEALTH NETWORK
NC7448603OtherAETNA
NC2123955OtherCIGNA
NC891327FMedicaid
NC1327FOtherBCBS
NCI06073Medicare UPIN
NC2026264Medicare ID - Type Unspecified