Provider Demographics
NPI:1952378622
Name:MATISKI, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:MATISKI
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 1:3930 E MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-4045
Mailing Address - Country:US
Mailing Address - Phone:602-992-2862
Mailing Address - Fax:
Practice Address - Street 1:1625 E NORTHERN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3960
Practice Address - Country:US
Practice Address - Phone:602-200-9021
Practice Address - Fax:602-200-9087
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18682207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ288250Medicaid
AZWMBHD08Medicare ID - Type Unspecified
AZ288250Medicaid