Provider Demographics
NPI:1548502586
Name:MATOSICH, STEPHENIE (DO)
Entity type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:
Last Name:MATOSICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:624 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2139
Practice Address - Country:US
Practice Address - Phone:509-626-9900
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2013-03-16
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39229207Q00000X
MS25337207Q00000X, 207VX0000X
WATO60905528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC392293Medicaid
SCP01772182OtherRAILROAD MEDICARE
SC392293Medicaid