Provider Demographics
NPI:1538788732
Name:MATZKE, DYLAN SUPAK
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:SUPAK
Last Name:MATZKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DYLAN
Other - Middle Name:NICOLE
Other - Last Name:SUPAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:675 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-3251
Mailing Address - Country:US
Mailing Address - Phone:979-966-8992
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 420
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3007
Practice Address - Country:US
Practice Address - Phone:832-325-7280
Practice Address - Fax:713-512-7104
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV9938208800000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208800000XAllopathic & Osteopathic PhysiciansUrology