Provider Demographics
NPI:1902900079
Name:MATTSON, MARK WARREN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WARREN
Last Name:MATTSON
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:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-1337
Mailing Address - Country:US
Mailing Address - Phone:276-236-3210
Mailing Address - Fax:276-236-8780
Practice Address - Street 1:225 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2228
Practice Address - Country:US
Practice Address - Phone:276-236-6906
Practice Address - Fax:276-236-7179
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030930208600000X
NC22944208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007335288Medicaid
VA020000748Medicare PIN
C85362Medicare UPIN