Provider Demographics
NPI:1134387830
Name:MATTOCKS, COLLEEN JAMES (DO)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:JAMES
Last Name:MATTOCKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:E
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3707 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3658
Mailing Address - Country:US
Mailing Address - Phone:540-725-7800
Mailing Address - Fax:540-725-7849
Practice Address - Street 1:3707 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3658
Practice Address - Country:US
Practice Address - Phone:540-725-7800
Practice Address - Fax:540-725-7849
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37742207Q00000X
390200000X
VA0102202851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV2490AOtherMEDICARE PTAN