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General NPI Number Information
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NPI Number | 1700881190
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Entity Type | Individual
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Provider Name | ROBERT K MATLACK JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/14/2005
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Last Update Date | 11/16/2009
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Provider Practice Location Address
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Address Line | 2587 RAVENHILL DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-5451
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Country | US
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Telephone | 910-323-1543
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Fax | 910-485-1257
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Provider Business Mailing Address
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Address Line | 2587 RAVENHILL DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-5451
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Country | US
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Telephone | 910-323-1543
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Fax | 910-485-1257
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 200201282
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 20021282
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License Number State | NC
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