Provider Demographics
NPI:1548336662
Name:MATTESON, REID ALAN (C PED)
Entity type:Individual
Prefix:MR
First Name:REID
Middle Name:ALAN
Last Name:MATTESON
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S VAN EPS AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-1734
Mailing Address - Country:US
Mailing Address - Phone:605-331-3067
Mailing Address - Fax:605-331-3083
Practice Address - Street 1:112 S VAN EPS AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-1734
Practice Address - Country:US
Practice Address - Phone:605-331-3067
Practice Address - Fax:605-331-3083
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD20371Medicare UPIN