Provider Demographics
NPI:1114116662
Name:WILLIAM J MATTOX MD PA
Entity Type:Organization
Organization Name:WILLIAM J MATTOX MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATTOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-270-2515
Mailing Address - Street 1:16150 US HIGHWAY 17 N STE C
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-7308
Mailing Address - Country:US
Mailing Address - Phone:910-270-2515
Mailing Address - Fax:910-270-3544
Practice Address - Street 1:16150 US HIGHWAY 17 N STE C
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-7308
Practice Address - Country:US
Practice Address - Phone:910-270-2515
Practice Address - Fax:910-270-3544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDF0388OtherPALMETTO GBA-RAILROAD MCR
NCC80658Medicare UPIN
NCDF0388OtherPALMETTO GBA-RAILROAD MCR