Basic Information
| Provider Information | |||||||||
| NPI: | 1306034582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTOCH | ||||||||
| FirstName: | INGERLISA | ||||||||
| MiddleName: | WENCHE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7268 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708186788 | ||||||||
| FaxNumber: | 9706690159 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 N. BOISE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805384204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708186788 | ||||||||
| FaxNumber: | 9706690159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | DR.0049136 | CO | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ZD0900X | 49136 | CO | Y | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.