1669577573 NPI number — ROBERT JOHN MATEJKA DO

Table of content: ROBERT JOHN MATEJKA DO (NPI 1669577573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669577573 NPI number — ROBERT JOHN MATEJKA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATEJKA
Provider First Name:
ROBERT
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1669577573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2146 POWDERKEG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84093-1784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-944-8866
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3460 PIONEER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST VALLEY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84120-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-993-9526
Provider Business Practice Location Address Fax Number:
801-733-5618
Provider Enumeration Date:
09/14/2006

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: 207L00000X , with the licence number:  319892-1204 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 700 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 224510 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 607111900 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1020088 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: PRA01843 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 609345 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107007846103 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 81627 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com