Provider Demographics
NPI:1073545950
Name:MATTSON, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:MATTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 COLBY ST
Mailing Address - Street 2:118
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2059
Mailing Address - Country:US
Mailing Address - Phone:800-943-8099
Mailing Address - Fax:510-845-0522
Practice Address - Street 1:3010 COLBY ST
Practice Address - Street 2:118
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2059
Practice Address - Country:US
Practice Address - Phone:800-943-8099
Practice Address - Fax:510-845-0522
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG33079207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG33079OtherBLUE CROSS
CA00G330790Medicaid
CA250007310OtherRAILROAD MEDICARE PIN
CAG33079OtherSTATE LICENSE
CA00G330790OtherBLUE SHIELD
CAG33079OtherSTATE LICENSE