Healthcare Provider Details

I. General information

NPI: 1265479273
Provider Name (Legal Business Name): ROBERT C MATLOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 LONDONDERRY DR
WACO TX
76712-7929
US

IV. Provider business mailing address

PO BOX 18962
BELFAST ME
04915-4084
US

V. Phone/Fax

Practice location:
  • Phone: 254-537-6464
  • Fax: 254-537-6466
Mailing address:
  • Phone: 800-566-5050
  • Fax: 254-537-6869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberK3613
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK3613
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License NumberK3613
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: