Basic Information
| Provider Information | |||||||||
| NPI: | 1467190736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INGERLISA MATTOCH MD INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIAGA PATHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7268 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9706670847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 BOISE AVE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805384204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7081867889 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2022 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | MATTOCH | ||||||||
| AuthorizedOfficialFirstName: | INGERLISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 9708186788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ZP0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZD0900X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.