Healthcare Provider Details

I. General information

NPI: 1952378622
Provider Name (Legal Business Name): THOMAS J. MATISKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E NORTHERN AVE SUITE 103
PHOENIX AZ
85020-3960
US

IV. Provider business mailing address

3930 E MOUNTAIN VIEW RD
PHOENIX AZ
85028-4045
US

V. Phone/Fax

Practice location:
  • Phone: 602-200-9021
  • Fax: 602-200-9087
Mailing address:
  • Phone: 602-992-2862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number18682
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: