Basic Information
| Provider Information | |||||||||
| NPI: | 1811337439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATZEN | ||||||||
| FirstName: | DORIAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATTINGLY | ||||||||
| OtherFirstName: | DORIAN | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 840026 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062126965 | ||||||||
| FaxNumber: | 8062126278 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 BELL ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791095714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062124835 | ||||||||
| FaxNumber: | 8062120900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 04927 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 04927 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 04927 | KY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | Q9436 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 360140301 | 05 | TX | MEDICAID |