Provider Demographics
NPI:1952343543
Name:MATLOCK, GORDON A (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:A
Last Name:MATLOCK
Suffix:
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:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8461
Mailing Address - Country:US
Mailing Address - Phone:360-577-6628
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-577-6628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1540608Medicaid
000700093Medicare ID - Type Unspecified
WA1540608Medicaid