Provider Demographics
NPI:1770513038
Name:MATTSON, GREG D (MD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:D
Last Name:MATTSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:2600 65TH AVENUE
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-3024
Mailing Address - Country:US
Mailing Address - Phone:715-294-2111
Mailing Address - Fax:715-294-2111
Practice Address - Street 1:2600 65TH AVENUE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-3024
Practice Address - Country:US
Practice Address - Phone:715-294-2111
Practice Address - Fax:715-294-5758
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-10-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI34072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34072OtherSTATE MEDICAL LICENSE
MN992063300Medicaid
WI31917000Medicaid
MN992063300Medicaid
E37067Medicare UPIN
WI0002-49155Medicare ID - Type Unspecified