Healthcare Provider Details

I. General information

NPI: 1538162912
Provider Name (Legal Business Name): MICHAEL A MATYAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 CONSTITUTION PL NE SUITE 202
ALBUQUERQUE NM
87110-7607
US

IV. Provider business mailing address

8020 CONSTITUTION PL NE SUITE 202
ALBUQUERQUE NM
87110-7607
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-3096
  • Fax: 505-998-3100
Mailing address:
  • Phone: 505-998-3096
  • Fax: 505-998-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberH8241
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2013-0288
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: