M & T Dermatology Services LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

M & T DERMATOLOGY SERVICES LLC

Practice address

2829 S Jackson Ave
Joplin, MO 64804-2525

Phone

(417) 624-0440

Fax

(417) 624-9652

NPI assigned

Oct 13, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark Stephen Matlock, MD

Title

Owner

Phone

(417) 624-0440

Specialties & licenses 1

Addresses

Other identifiers 2

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1129161600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1227052800000",
    "number": "1083602015",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2829 S JACKSON AVE",
            "city": "JOPLIN",
            "state": "MO",
            "postal_code": "648042525",
            "telephone_number": "417-624-0440",
            "fax_number": "417-624-9652"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2829 S JACKSON AVE",
            "city": "JOPLIN",
            "state": "MO",
            "postal_code": "648042525",
            "telephone_number": "417-624-0440",
            "fax_number": "417-624-9652"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "M & T DERMATOLOGY SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-13",
        "last_updated": "2008-11-19",
        "status": "A",
        "authorized_official_last_name": "MATLOCK",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "STEPHEN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "417-624-0440",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "506068501",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "DA0571",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.