Provider Demographics
NPI:1811494727
Name:MATLOCK, STEPHEN MICHAEL
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:MATLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 W 135TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-1201
Mailing Address - Country:US
Mailing Address - Phone:913-451-7546
Mailing Address - Fax:
Practice Address - Street 1:7901 W 135TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223
Practice Address - Country:US
Practice Address - Phone:913-451-7546
Practice Address - Fax:913-663-2411
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-46232207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery