Provider Demographics
NPI:1134200926
Name:MATLAK, MICHAEL E (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:MATLAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MARIO CAPECCHI DR
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-2950
Mailing Address - Fax:801-662-2980
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:SUITE 2600
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-2950
Practice Address - Fax:801-662-2980
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1605921205208600000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05572Medicaid
000001419Medicare ID - Type Unspecified
UT05572Medicaid