Healthcare Provider Details

I. General information

NPI: 1174904254
Provider Name (Legal Business Name): MARSEL MATKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PAGE AVE
JACKSON MI
49201-2419
US

IV. Provider business mailing address

1 FORD PL STE 2E
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4800
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301503479
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301503479
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: