1114911369 NPI number — IGOR EVAN MATWIJIW M.D.

Table of content: IGOR EVAN MATWIJIW M.D. (NPI 1114911369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114911369 NPI number — IGOR EVAN MATWIJIW M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATWIJIW
Provider First Name:
IGOR
Provider Middle Name:
EVAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114911369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
919 HIDDEN RDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75038-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-282-2711
Provider Business Mailing Address Fax Number:
469-282-0996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2602 SAINT MICHAEL DR STE 201B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-2320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-614-5530
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  J4910 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200298690A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 126488902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 460002032 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 126488906 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4321815 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 87592Z . This is a "HMO BLUE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 87281J . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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