Healthcare Provider Details

I. General information

NPI: 1114911369
Provider Name (Legal Business Name): IGOR EVAN MATWIJIW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 SAINT MICHAEL DR STE 201B
TEXARKANA TX
75503-2320
US

IV. Provider business mailing address

919 HIDDEN RDG
IRVING TX
75038-3813
US

V. Phone/Fax

Practice location:
  • Phone: 903-614-5530
  • Fax:
Mailing address:
  • Phone: 469-282-2711
  • Fax: 469-282-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberJ4910
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: