Basic Information
| Provider Information | |||||||||
| NPI: | 1902900079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | WARREN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1337 | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243331337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762363210 | ||||||||
| FaxNumber: | 2762368780 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243332228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762366906 | ||||||||
| FaxNumber: | 2762367179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101030930 | VA | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 22944 | NC | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 007335288 | 05 | VA | MEDICAID |