Healthcare Provider Details

I. General information

NPI: 1083602015
Provider Name (Legal Business Name): M & T DERMATOLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 S JACKSON AVE
JOPLIN MO
64804-2525
US

IV. Provider business mailing address

2829 S JACKSON AVE
JOPLIN MO
64804-2525
US

V. Phone/Fax

Practice location:
  • Phone: 417-624-0440
  • Fax: 417-624-9652
Mailing address:
  • Phone: 417-624-0440
  • Fax: 417-624-9652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK STEPHEN MATLOCK
Title or Position: OWNER
Credential: MD
Phone: 417-624-0440