Provider Demographics
NPI:1902298060
Name:THOMAS S MATYSIK DPM
Entity Type:Organization
Organization Name:THOMAS S MATYSIK DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MATYSIK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:352-726-0331
Mailing Address - Street 1:2246 HIGHWAY 44 W
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-3808
Mailing Address - Country:US
Mailing Address - Phone:352-726-0331
Mailing Address - Fax:352-726-7189
Practice Address - Street 1:2246 HIGHWAY 44 W
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3808
Practice Address - Country:US
Practice Address - Phone:352-726-0331
Practice Address - Fax:352-726-7189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1995213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052129900Medicaid
FLU02594Medicare UPIN
FL65114Medicare PIN